Every finding on record at Malley Transitional Care Center

Based on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for accidents out of 18 sample residents remained as free from accidents and hazards as possible.Resident #4, who had diagnoses of multiple sclerosis (a progressive neurological condition), polyneuropathy (a disease featuring weakness, numbness and burning pain) and anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), was admitted to the facility on [DATE]. Resident #4 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift).On 4/7/26 staff were transferring Resident #4 using the smaller Hoyer lift. According to the resident's weight, the resident required the larger Hoyer lift. The resident began to fall and was lowered to the ground.On 4/9/26 at 9:00 p.m. certified nurse aide (CNA) #2 and CNA #3 were transferring Resident #4 from his motorized wheelchair to his bed using a Hoyer lift. During the transfer the sling attached to the Hoyer lift's sling bar (a bar with two safety latches on each end the sling attaches to) came undone. The resident fell onto the floor and hit his head on the Hoyer lift and the floor. The resident experienced increased pain, sustained a hematoma and was sent to the emergency room (ER) for further evaluation. The resident was diagnosed with a head injury. Resident #4 reported the incident was very scary and he had had increased pain to his head since the incident. Specifically, the facility failed to ensure Resident #4 was transferred safely using the Hoyer lift.Findings include: Record review, observations and interviews confirmed the facility corrected the deficient practice related to Resident #4's fall prior to the onsite investigation on 5/11/26 to 5/14/26, which resulted in the deficiency being cited as past non-compliance with a correction date of 4/17/26.I. Incident on 4/9/26On 4/9/26 CNA #2 and CNA #3 were transferring Resident #4 using the Hoyer lift. During the transfer, one of the sling loops came unhooked and the resident fell to the ground, striking his head. Resident #4 was transferred to the hospital and diagnosed with a head injury. II. Facility plan of correctionA. Immediate action to correct the deficient practiceResident #4 was transferred to the hospital for evaluation and treatment. An interview was completed with the resident when he returned and his care plan was updated. B. Identification of other residentsThe nursing home administrator (NHA), the director of nursing (DON) and the regional clinical resource reviewed and audited the care plans and assessments of all residents who required assistance with transferring via mechanical lifts. There were 48 residents who were dependent on staff for transfers and required the use of a mechanical lift. The facility updated the facility assessment to reflect the identified 48 residents who were dependent on the assistance of a mechanical lift.C. Systemic changesOn 4/10/26 CNA #3, who was hired on 1/16/26, received one-to-one education regarding appropriate transfers. The training included making sure the sling loops were properly secured before proceeding with the transfer. Hoyer lift transfer competency skills checklist were met and completed. On 4/10/26 CNA #2, who was hired on 1/8/24, received one-to-one education regarding appropriate transfers. The training included making sure the sling loops were properly secured before proceeding with the transfer. Hoyer lift transfer competency skills checklist were met and completed. All nursing staff were re-educated on proper mechanical lift procedures and provided a return demonstration of knowledge by 4/12/26.D. MonitoringThe DON/designee would conduct three random Hoyer transfer audits per week via observation to ensure proper transfers were conducted, and that staff were competent to perform the transfers. Audits would be documented via excel spreadsheet and reviewed monthly in the quality assurance and program improvement (QAPI) meeting for a minimum of 12 weeks or until substantial compliance had been achieved. III. Facility policy and procedureThe Activities of Daily Living (ADL), Lifting and Movement of Residents policy and procedure, revised 5/13/26, was provided by the DON on 5/13/26 at 10:04 a.m. It read in pertinent part, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort, and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Staff responsible for direct resident care will be trained in the use of manual (gait/transferbelts, lateral boards) and mechanical lifting devices. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. Only staff with documented training on the safe use and care of the machines and equipment used in this facility will be allowed to lift or move residents. Mechanical lifts are only to be operated with two staff members during transfers. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policies and procedures regarding use of equipment and safe lifting techniques. Mechanical lifts shall be made readily available and accessible to staff 24 hours a day. Back-up battery packs on remote chargers shall be provided as needed so that lifts can be used 24 hours a day while batteries are being recharged.IV. Manufacturer recommendationsThe user instruction manual for the Hoyer HPL700 mechanical lift, dated 2024, was provided by the NHA on 5/13/26 at 11:10 a.m. It read in pertinent part, Read and understand the user instruction manual before using the Hoyer HPL700 lift. Do not lift a patient unless you are trained and competent to do so. Always carry out the daily check list located towards the end of the manual before using the lift. Always fit the sling according to the instructions provided (user instructions). Always carry out lifting operations according to the instructions in the user manual. The Hoyer HPL700 has a six-point bari loop spreader bar. The six-point system uses slings with webbing loops which allows positioning adjustments by selecting different colored straps. The six-point system attaches to the spreader bar hooks via loop straps. Each sling is supplied with instructions. Please study the instruction guide before use.V. Resident #4A. Resident statusResident #4, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), polyneuropathy, anxiety disorder, insomnia, dyspepsia (chronic indigestion), cervicalgia (neck pain), weakness and unspecified chronic pain. The 3/3/26 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on staff assistance for eating, oral hygiene, toileting hygiene, shower/bathing, upper/lower body dressing, personal hygiene, rolling left and right, chair to bed-to-chair transfers and shower transfers. The MDS assessment revealed the resident was on a scheduled pain regimen and did not receive PRN (as needed) pain medication. The assessment revealed the resident experienced pain frequently but it rarely or not at all affected sleep but occasionally interfered with day to day activities. The assessment revealed the resident's worst pain was 5 on a scale of 0 to10, with 0 being no pain and 10 as the worst pain he could imagine. B. Resident and resident representative interviewResident #4 was interviewed on 5/12/26 at 3:45 p.m. Resident #4 said he had two falls recently. He said the first fall, on 4/7/26, occurred when two staff members used a smaller Hoyer lift instead of the usual big one to transfer him. He said he was not sure why they used that one and if they had tried hard enough to find the big one. He said the sling size was always the same size but the Hoyer lift should have been the big one. He said when the smaller Hoyer lift started to tip during the transfer, they lowered him to the ground. Resident #4 said the second fall occurred on 4/9/26, two days later, and was much worse and scary. He said the two staff members were transferring him via a Hoyer lift from his wheelchair to the bed. He said the sling unhooked and he fell head first landing on his head, first hitting the Hoyer lift, which was metal and then the floor. He said he went to the emergency room (ER) where he was evaluated. Resident #4 said he had 10 out of 10 head and neck pain after the fall, especially on the left back side of head. Resident #4 said he had headaches afterwards and he still had neck pain at a level of 6 to 7 out 10 today (5/12/26), five weeks later. He said prior to the fall, he did not have neck pain. He said he believed the CNAs had gotten training after the fall with the Hoyer lift. The resident's representative was interviewed on 5/13/26 at 9:45 a.m. The resident's representative said the nurse manager told her there had been only two working Hoyer lifts on the unit and that may be why they used the smaller Hoyer lift on Resident #4 with his first fall on 4/7/26. The resident's representative said Resident #4 did not have a history of neck pain prior to his second fall on 4/9/26. The resident's representative said Resident #4 had general chronic pain prior to his fall, but not specifically to the neck and head. The resident's representative said after the second fall, pain was the main issue that Resident #4 suffered. The resident's representative said she felt petrified when she heard he fell a second time during a Hoyer lift transfer and she was scared about his potential head injury and feared broken bones. The resident's representative said she knew it was the second fall in a week and it led her to feel really concerned about the quality of care and the skills of the staff providing his care. C. Facility investigationThe 4/9/26 facility investigation was provided by the DON on 5/13/26 at 1:05 p.m. The investigation revealed CNA #3 reported to the nurse that Resident #4 had fallen from the Hoyer lift while they were transferring him from his wheelchair to his bed. The investigation documented neurological checks were at baseline, no changes in mentation were noted at that time and a hematoma was noted by the nurse to the resident's left posterior head. The resident was sent to the ER for further evaluation. The resident returned to the facility on 4/10/26.The investigation documented that while Resident #4 was at the hospital, a computed tomography (CT - imaging) of the head and spine was done. The CT revealed no acute intracranial (skull) abnormalities, no fractures or subluxation (dislocation of bone) of the cervical spine. The resident returned to the facility with no new orders.The investigation documented CNA #2 and CNA #3 were interviewed. The CNAs said Resident #4 requested to be assisted in his bed. CNA #3 asked for assistance from CNA #2. Both CNAs stated that they checked that the loops were secured then went on to transfer the resident. Midway through the transfer they heard a noise. They noticed the left upper sling came off the hook, and the resident started to fall. The CNAs said the resident hit his head on the foot bar of the Hoyer lift.The investigation documented the root cause of the fall was the staff did not check to ensure the loops on the slings were secured.The investigation documented the staff were educated on making sure that sling loops were properly secured on the Hoyer lift prior to transfer.Resident #4 was interviewed by the facility for the 4/9/26 incident. Resident #4 stated that they were raising him and he felt himself starting to slip. He said he was not aware of what happened, he just knew he was sliding.The investigation included a timeline of events from 4/9/26. The timeline revealed the following: At 9:00 p.m. CNA #3 reported to the nurse that Resident #4 fell from the Hoyer lift. CNA #2 and CNA #3 stated Resident #4 fell from the Hoyer lift sling after one sling corner slid off. The unnamed registered nurse (RN) completed the assessment and noted a hematoma to the back of the left side of the resident's head. Neurological assessment revealed the resident was at baseline. The resident was talkative and complained of a headache. At 9:29 p.m. the on-call physician was contacted by the nurse, a report was given and the physician said to send the resident to the ER for further evaluation and treatment. At 9:45 p.m. the nurse contacted the resident's POA (power of attorney) and a report was given. The POA asked for the resident's sister to also be contacted. At 9:47 p.m. the nurse contacted the resident's sister and left a message on the answering machine to return the call. At 9:49 p.m. the nurse contacted the police department for ambulance transfer to the ER and a report was given and the nurse was informed that an ambulance was enroute to the facility. At 9:50 p.m. the paramedics arrived and the resident left the facility in stable condition via ambulance on a stretcher.At 10:07 p.m. the nurse received a return phone call from the resident's sister and gave her a report. At 10:09 p.m. the nurse called the hospital and gave a report to the ER nurse. At 10:18 p.m. the DON was notified and was given a report by the nurse. At 12:15 a.m. the facility received a call from the ER nurse stating the resident would return to the facility shortly. Head imaging was completed and revealed no bleeds and no fractures were noted. On 4/10/26 at 1:18 a.m. the resident returned to the facility in stable condition via stretcher. The resident's sister asked if full body imaging of the resident was completed. The facility contacted the ER and the nurse stated a CT was completed of the head, spine, and back was completed. The legs were not included. At 7:29 a.m. the resident reported pain 8 out of 10. D. Record reviewResident #4's fall care plan, revised 5/1/26, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, avoiding rearranging the furniture, ensuring the call light was within reach, ensuring that sling loops are properly secured prior to transfer and utilizing the larger Hoyer lift for all transfers.The 4/7/26 nursing progress note documented the nurse was informed by CNA #1 that Resident #4 was lowered to the floor by the CNAs during a transfer, the resident denied injury or pain and denied hitting his head, a full assessment was completed, initiated risk assessment, notified physician, non urgent voicemail line, and the resident did not want his family called. The 4/8/26 therapy note revealed Resident #4 had been lowered to the floor using the Hoyer lift as he was sliding in the sling. The resident was being transferred using the smaller lift while the bigger one was being repaired. The note documented Resident #4 would be transferred with the bigger one for safety.The 4/8/26 IDT fall committee note revealed Resident #4 fell at 5:00 p.m. in his room. The note documented notifications were given and the fall was witnessed with no injuries. The note documented predisposing factors included MS, weakness, poor trunk control and body habitus. The note documented prior to the fall, the resident was transferring to his wheelchair. The note documented interventions were to utilize the larger Hoyer lift.The 4/9/26 nursing progress note documented Resident #4 was being monitored for a witnessed fall on 4/7/26. The note documented the resident had 3 out of 10 pain at 10:38 a.m., but the resident currently denied any pain. The nursing progress note documented on 4/9/26 at 9:00 p.m. revealed Resident #4 sustained a fall. The evaluation revealed the resident had pain and was on the floor. The RN assessed and noted a hematoma to the left side of the back of head. The note documented it was recommended to send the resident to ER to evaluate, per the on-call physician.The 4/9/26 at 9:00 p.m. nurse note revealed the nurse was called to Resident #4's room by the CNA. Upon entering the room, the resident was supine on the floor mid-room. CNA #2 and CNA #3 stated that the resident fell from the Hoyer lift sling after one sling corner slid off. The resident stated he fell out. The RN completed the assessment, a hematoma was noted to the left side of the resident's posterior head, a neurological assessment was completed and the resident was at baseline. The resident was talkative and complained of a headache. The physician gave orders to send the resident to the ER for further evaluation and treatment. The resident's representative was contacted and a report was given. The representative asked for the resident's sister to also be contacted. The resident's sister was contacted and left a message on the answering machine to return the call. At 9:49 p.m. the police department was contacted for an ambulance transfer to the ER and a report was given and the nurse was informed an ambulance was enroute to the facility. The paramedics arrived and Resident #4 left the facility in stable condition via ambulance and a stretcher. The facility received a return call from the resident's sister and gave a report. A call was placed to the hospital and a report was given to the ER nurse. The DON was notified of the above. At 12:15 a.m. a phone call was received from an ER nurse stating the resident would return to the facility shortly, head imaging was completed with no bleeds and no fractures noted. At 1:18 a.m. Resident #4 returned to the facility in stable condition via stretcher. The resident's sister asked if full body imaging of the resident was completed. The nurse contacted the ER and the nurse stated a CT (computed tomography) of the resident's head, spine and back was completed, but not the resident's legs. The 4/9/26 hospital ER encounter note revealed the history of Resident #4's present illness was a headache and neck pain. The history report revealed that the resident was being moved with a lift and a strap became loose and the resident fell, hitting the left side of the back of the head onto the frame with subsequent discomfort. The resident noted associated neck discomfort on the left. The resident was given pain medication prior to arrival. The resident was diagnosed with an injury to the head.The 4/9/26 hospital CT scan revealed no acute intracranial abnormality and no fracture or subluxation of the cervical spine.The 4/10/26 hospital after visit summary revealed Resident #4 was seen for headache and neck pain with a diagnosis of injury to the head. The note documented a head injury as any trauma to the head. This could come from a blow or a sudden force. A head injury meant the blow to the head did not break the skull. The note documented common types of head injuries were concussions and brain contusions. The note documented if the brain had been shaken, this was a concussion. If the brain was bruised, this was a contusion. The damage may cause swelling or pressure on the brain. A head injury may be mild or severe. It would depend on how much swelling and pressure there was on the brain.There may still be brain damage even if there was no loss of consciousness. Some people had a headache.The 4/10/26 at 9:32 a.m. IDT fall committee note revealed review of the fall on 4/9/26 at 9:00 p.m. in Resident #4's room. The physician and the resident's representative were notified.The fall was witnessed and the resident sustained a knot to the back of head. The note documented predisposing factors included MS, weakness, poor trunk control, body habitus, and required hoyer with transfers. The resident was transferred to a wheelchair via Hoyer lift. The note documented the staff were to ensure that sling loops were properly secured on the Hoyer lift prior to transfer.The 4/10/26 at 9:33 a.m. therapy note revealed Resident #4 had a fall, that was witnessed, from the Hoyer last night (4/9/26). The CNAs reported a sling loop slipped off the Hoyer lift, causing the resident to slide off the sling. The nursing staff was in-serviced on ensuring sling loops were properly secured prior to transfer. The 4/10/26 at 5:01 p.m. follow up note revealed all neurological checks were completed and were within normal limits. The resident complained of increased pain to the back of his neck and low back. The note documented scheduled pain medications were given with some relief. No visual bruising was present at that time. The 4/11/26 at 6:46 p.m. nurse note revealed Resident #4 was on alert charting for a fall with neurological checks that were within normal limits. The resident complained of pain to his neck and lower back.The 4/12/26 at 3:03 p.m. nurse note revealed the resident remained on alert charting for a recent fall. The note documented the resident remained on every four hour neurological checks. The resident was at baseline for mentation and range of motion. The resident complained of pain in the back of head, scheduled pain medication was administered as ordered with positive effect.The 4/13/26 primary care physician visit note revealed Resident #4 requested to be seen. The resident reported a recent fall from a sling during a transfer and reported striking his head. The resident had pregabalin (anticonvulsant and nerve pain medication), Tylenol and oxycodone-acetaminophen for chronic pain, and was wanting ibuprofen (a nonsteroidal anti-inflammatory drug used to relieve pain, and decrease inflammation) for a few days. The assessment and plan for the pain was to start ibuprofen 400 mg (milligrams) every eight hours PRN (as needed) for one week and recommended physician visit follow-up for pain.Review of Resident #4's electronic medical record (EMR) revealed he received PRN ibuprofen for a headache on 4/15/26, 4/16/26, 4/22/26 and 4/27/26. The 4/27/26 primary care physician visit note revealed Resident #4 requested to be seen. The chief complaint was the resident reported ongoing pain on the side of the neck and a headache. The resident believed pain was from a recent fall from a sling during transfer. The resident started ibuprofen PRN every eight hours for one week, extended to an additional week, and would continue for another week. The note documented the physician ordered physical therapy and occupational therapy for pain and stiff neck, and that the resident may need upper body strengthening and core strengthening. The note documented the resident reported a recent fall from the lift sling during transfer, reported striking his head, he was seen in the ER and returned. The resident had a diagnosis of MS. The resident required the Hoyer lift for transfers and he recently fell approximately five to six feet from the sling to the floor striking his head.VI. Staff interviewsThe DON, the NHA and the regional clinical resource were interviewed together on 5/12/26 at 3:20 p.m. The DON, the NHA and the regional clinical resource said they completed CNA training with return demonstration and a whole plan of correction after Resident #4's fall on 4/9/26. The NHA said the facility completed maintenance checks of the mechanical lifts monthly and recorded through the computer system. The NHA said the type of Hoyer lift that Resident #4 used when he fell on 4/9/26 was a Hoyer HPL700 lift, which indicated that it could hold up to 700 lbs (pounds). The DON said that CNA #2 and CNA #3 received one-on-one education and a final warning regarding appropriate transfers. The DON said part of the training was ensuring the Hoyer lift sling loops were properly secured before proceeding with the transfer. The DON said the staff was given Hoyer lift training for proper use and safety with staff signatures, dated 4/10/26, and they completed a Hoyer lift competency skills check list. The DON said she was auditing three staff members a week via observation to ensure proper technique was used for the transfers.CNA #2 was interviewed on 5/13/26 at 1:03 p.m. CNA #2 said on the day that Resident #4 fell from the Hoyer lift (4/9/26), CNA #3 had asked her to help with the transfer. CNA #2 said they started to get him ready and she thought they had hooked up everything correctly. CNA #2 said they started doing the lift and transferring him to the bed and they noticed Resident #4 was slipping and by that time, he was falling. CNA #2 said he fell head first toward the left and hit the Hoyer lift leg first, then the floor. CNA #2 said CNA #3 went and got the nurse. CNA #2 said the nurse checked Resident #4 and concluded that the hook was not secured down all the way on the sling. CNA #2 said it was on her side. CNA #2 said she had completed Hoyer lift trainings over the time she had worked in the facility and completed new Hoyer lift training after Resident #4's fall. CNA #2 said she learned from the incident to be double checking that everything was hooked and in place properly. CNA #2 said Resident #4 let them know that his head was hurting. The DON and the NHA were interviewed together on 5/13/26 at 1:43 p.m. The NHA said the facility discussed the 4/9/26 Hoyer lift incident in the QAPI meeting on 4/15/26 and were continuing to monitor. The DON said on 4/7/26, during Resident #4's first fall, the Hoyer lift on Resident #4's unit was broken, so the staff took the smaller Hoyer lift from the East unit but the smaller lift started tipping during the transfer so they lowered Resident #4 to the floor with no injury. The DON said the facility had now added new physician orders for the size of sling and the size of the Hoyer lift to be used for transfers and care plans were also updated. The DON said on 4/9/26, during Resident #4's second fall, CNA #2 and CNA #3 checked the Hoyer lift loops and did the transfer. She said Resident #4 started falling to the left side and the loop came off the hook. The DON said the CNAs did not tug on the loop to make sure it was secured, they had only looked at it. The DON said Resident #4 fell out to the left side, the sling came off the hook, and he fell and hit his head on the foot of the Hoyer lift and then the floor. She said the CNA got the nurse and an assessment was done and the nurse noticed a bump on the left side of Resident #4's head and sent him to the hospital for further evaluation. The DON said Resident #4 fell at 9:00 p.m. on 4/9/26 and returned back to the facility the next morning. The DON said Resident #4's care plan was updated and the root cause of the fall was insufficient checking of the loop. The DON said the new interventions were to double check and tug on the loop and education on transfers with demonstrated competencies was completed with staff. The DON said auditing and reviewing of all staff members, including agency staff was completed. The NHA said it was important that the facility assessment reflect the resident population in order to have proper supplies, training and staff. The NHA said he would do an add-on QAPI due to the substantial modification that was needed because the current facility assessment said the facility had 18 dependent residents for transfers but the audit revealed there were 48 dependent residents for transfers with use of a Hoyer lift. The NHA said the facility had a total of 13 Hoyer lifts for the facility with another one on order. The medical director (MD) was interviewed on 5/13/26 at 2:35 p.m. The MD said he was in the facility at least weekly and also saw residents as patients. The MD said the roles he provided while in the facility included seeing patients, attending QAPI meetings, medical director and attending psychotropic meetings. The MD said he sometimes provided education to staff on certain topics, during QAPI meetings and one-to-one with nurses as needed. The MD said he reviewed the pharmacist forms, infection control reports, QAPI reports and reviewed each department. The MD said he provided oversight and follow-up and suggestions to the facility for improvements as needed. The MD said he reviewed his own patients' medical records and other residents upon request, such as for a fall or a hospital admission. The MD said he just did a specific chart review today (5/13/26) on Resident #4 upon request of the facility. The MD said he was aware of Resident #4's fall from the Hoyer lift on 4/9/26 and he was aware that the facility had conducted further staff training for transfers with a mechanical lift. The MD said he felt Resident #4 had been attended to very well after his fall, evaluated right away and sent to the ER. The MD said Resident #4's primary care physician had seen Resident #4 several times since the fall and the resident spoke for himself very well. The MD said Resident #4's pain would be expected for a while after this kind of injury, anywhere from a few weeks to a few months. The MD said he was not aware that the facility assessment (last reviewed August 2025) noted there were 18 residents who were dependent for transfers and that after the facility conducted an audit (on 4/10/26), it was noted that there were 48 residents who were dependent for transfers with use of a Hoyer lift. The MD said they would look at that discrepancy at the next QAPI meeting.

Based on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#14) of five residents reviewed for abuse out of 18 sample residents.Specifically, the facility failed to protect Resident #14 from physical abuse by Resident #10.Findings include:I. Facility policy and procedureThe Abuse Prevention policy and procedure, revised October 2024, was provided by the nursing home administrator (NHA) on 5/14/26 at 1:45 p.m. It read in pertinent part, It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: Staff had knowledge of the individual residents' care needs; Assess, care plan, and monitor residents with a history of aggressive behaviors, behaviors such as entering other residents' rooms, self-injurious behavior, communication disorders, totally dependent on staff. If the suspected perpetrator is another resident: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined; If a room change is appropriate, advise residents' families of the change and room location.II. Incident of physical abuse by Resident #10 towards Resident #14 on 4/2/26A. Facility investigationThe facility abuse investigation report of the incident involving Resident #10 and Resident #14 was provided by the NHA on 5/12/26 at 11:05 a.m.The 4/2/26 facility investigation revealed that at approximately 10:00 p.m. on 4/2/26 Resident #10 made contact with Resident #14 by throwing objects at her while Resident #14 was in bed. Resident #21 (Resident #14's roommate) reported to staff that Resident #10 had wandered into their room and was throwing things from the bedside table, such as Kleenex and papers. Resident #21 said there was a chance that one of the items thrown may have made contact with her roommate, Resident #14. Resident #14, who was allegedly contacted with the items, was assessed for injury with no pain or injury and no change from baseline. A stop sign was placed on the residents' door to prevent any wandering into the room.-However, nursing progress notes documented on 4/3/26 revealed Resident #14 had a headache related to the incident (see record review below).The investigation documented Resident #10 had severe cognitive impairments. Resident #10 had a history of behavioral issues related to dementia.The investigation documented Resident #14 was cognitively intact. The investigation documented the occurrence was not witnessed and staff removed Resident #10 from Resident #14's room.The investigation documented Resident #14 was interviewed and she reported that a crazy female resident came into her room and started going through her drawers and threw items at her, including paper and Kleenex. She thought Resident #10 threw something at the back of her head and lower back. She said she could not really see this as her body was facing the wall and she could not physically move to see. She said she did not feel injured. She said she just felt confused as to what was going on. Resident #10 kept telling her that she had all the money and seemed really mixed up. Her roommate was helpful and went and got help. The investigation documented Resident #10 was interviewed and she was unable to explain why she had the encounter with the other resident and did not recall anything that occurred.The investigation documented Resident #21was interviewed and she did not visually witness Resident #10 begin the encounter with Resident #14. The investigation documented that staff came to intervene and confirmed that Resident #10 was in the room and that papers and Kleenex were on the floor. Resident #10 was holding a bottle of shampoo, but allowed staff to put that down and was redirected to her own room. The facility's investigation conclusion documented Resident #10 had wandered into Resident #14's side of the room and did throw items. The investigation documented the allegation was not verified as Resident #14 denied any pain or psychosocial affect related to the interaction. Resident #14 was understanding of the other residents' cognitive deficits. The investigation documented the facility was unable to determine the intention of Resident #10's actions, she did not recall the event and had significant cognitive deficits associated with dementia. Prior to this encounter, she had not had any known intrusive wandering episodes.-However, abuse occurred due to the willful actions of Resident #10 throwing multiple objects at Resident #14, hitting her in the back of the head causing her pain. B. Resident #10 (assailant)1. Resident statusResident #10, age greater than 65, was admitted on [DATE]. According to the May 2026 computerized physician orders (CPO), diagnoses included congestive heart failure (CHF), type 2 diabetes mellitus, chronic kidney disease, major depressive disorder and dementia with behavioral disturbances.The 4/9/26 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. She was dependent on staff assistance for toileting hygiene, showers, shower and toilet transfers, chair to bed transfers, and sit to stand transfers. She required substantial/maximal assistance with rolling left and right, sitting to lying down, personal hygiene, upper and lower body dressing, oral hygiene, and wheelchair mobility. She required setup or clean-up assistance with eating. The assessment revealed she had potential indicators of psychosis, including delusions. She had behavioral symptoms including other behavioral symptoms not directed toward others that occurred every one to three days. She had wandering behaviors that occurred every one to three days. 2. Record reviewThe behavioral care plan, initiated 5/11/26 (during the survey), revealed Resident #10 was at risk for psychosocial well-being and behaviors related to dementia with behavioral disturbance, anxiety, major depressive disorder, impaired cognition, and impaired thought processes. Pertinent interventions included allowing time to answer questions and to verbalize feelings, perceptions, and fears, redirecting the resident to a quiet area when overstimulated, explaining care and transitions before initiating, encouraging participation from the resident who depended on others to make decisions, and needed assistance/supervision/support with identification of potential solutions to present problems.The 4/3/26 nursing note revealed that Resident #10 had wandered into Resident #14's room and went through the resident's drawers, found some paperwork and threw that at Resident #14. Resident #10 found a Kleenex box and threw that at Resident #14 hitting her. Resident #10 also attempted to throw a shampoo bottle but it was too heavy and fell on the floor. Resident #14 reported that Resident #10 came into her room and went through her possessions and threw some of it at her and hit her. A complete skin assessment was performed on Resident #14 and Resident #10 was removed from Resident #14's room and taken to her own room and assisted into bed. Resident #10 was placed on 15-minute checks for 72 hours, per facility policy.The 4/3/26 change of condition note revealed Resident #10 had behavioral symptoms. The nurse note revealed Resident #10 had increasing anxiety and aggressive behaviors (both physical and verbal). Resident #10 had as needed (PRN) Ativan (a medication that produces a calming effect) but was not administered with night medications due to calm behaviors with the nurse. Resident #10 was removed from Resident #14's room without incident and was calm while being prepared for bed. She was placed on 15-minute checks for her safety and the safety of other residents.The 4/3/26 social services note documented that Resident #10 had exhibited increased anxiety, paranoia and throwing items the night before when she had wandered into a different room from her own. The staff redirected her and in the morning she was resting until around lunchtime. Resident #10 was being treated for an infection and started antibiotics on 4/2/26. The social services director (SSD) reached out to a community provider and they would be reviewing options for a possible memory care placement. Behavioral health was consulted and would be starting Hydroxyzine to treat anxiety and continue with other medications. Staff were continuing with close line of sight monitoring. The plan was to update the care plan and psychosocial alert charting was in place.C. Resident #14 (victim)1. Resident statusResident #14, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2026 CPO, diagnoses included multiple sclerosis (a chronic and progressive neurological disorder), respiratory failure, depressive episodes, quadriplegia (the partial to complete paralysis of all four limbs, both arms, legs and torso) and anxiety disorder. The 1/24/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent for care and required assistance with eating, oral hygiene, toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left and right, chair to bed and bed to chair transfers, and shower transfers. The assessment revealed no behaviors or rejection of care.2. Resident interviewResident #14 was interviewed on 5/14/26 at 1:05 p.m. Resident #14 said she had moved to another room since the incident with Resident #10 on 4/2/26. She said she moved to a different hallway in order to be roommates with her husband. Resident #14 said that Resident #10 made her feel very nervous. She said Resident #10 had found out where she moved to and had come into her room twice again since the incident. Resident #14 said that Resident #10 had made friends with her husband and that was really a problem because he did not help protect her from Resident #10. She said when she heard Resident #10's voice coming into her room, she told her to get out! Resident #14 said that Resident #10 came into her room yesterday (5/13/26) and two days before that. Resident #14 said she did not know there was no stop sign on the door, like in her other room. Resident #14 said she told the certified nurse aide (CNA) that Resident #10 had come into her room. Resident #14 said during the 4/2/26 incident, Resident #10 had come into her room at 10:00 p.m. at night and had thrown things at her and had hit her in the back of her head. Resident #14 said that she was hit in the head with something that Resident #10 had thrown at her. Resident #14 said that Resident #10 was saying that she was taking her money. Resident #14 said it was so invasive that Resident #10 came into her room and threw things at her and messed up her room. Resident #14 said that Resident #10 had her in tears after she hit her in the head. Resident #14 said the police had come to meet with her but she did not file assault charges because the police said it was not worth it because of Resident #10's dementia. Resident #14 said she continued to be scared of Resident #10 and she continued to make her nervous. Resident #14 said she had head pain for one to two weeks after getting hit in the head. Resident #14 said she did not walk so she could not get away from Resident #10 and that made her feel vulnerable. 3. Resident's roommate interviewResident #21, who was Resident #14's previous roommate, was interviewed on 5/14/26 at 1:22 p.m. She said she was Resident #14's roommate during the incident on 4/2/26. Resident #21 said Resident #10 rolled into their room at 10:00 p.m. at night and said she wanted her money and Resident #14 had her money. Resident #21 said Resident #10 started throwing things from the bedside table at Resident #14 and hit her at least two to three times. Resident #21 said she was throwing things, such as a bottle of mouthwash, a brush, a bottle of lotion, a box of Kleenex, Amazon packages and shampoo and other products. Resident #21 said she tried to get Resident #10 out of the room but she was acting like a bully, so she snuck out of the room to the hallway to get help. 4. Record reviewResident #14's depression care plan, revised 11/2/25, revealed behavior monitoring was in place to track if the resident was sad, tearful or irritable. Pertinent interventions included monitoring and recording mood to determine if problems seemed to be related to external causes, such as medications, treatments, or concern over diagnosis, with the goal of the resident having a positive adjustment to the facility.-There were no progress notes or documentation related to the incident on 4/2/26 in Resident #14's electronic medical record (EMR). The 4/3/26 nursing note revealed Resident #14 was complaining of a slight headache. The nurse noted no bumps or swelling. The nurse palpated (to examine a part of the body by touching or pressing it with the hands or fingers) the resident's posterior (back) head and the resident complained of pain when palpating the middle of the back of the head. The resident stated she felt fine and it was okay. The nurse inquired if the resident needed any pain medication or ice pack. The resident said no and said she was okay and was just going to rest. The 4/3/26 social services note revealed that the SSD spent some one-to-one time with Resident #14 to offer psychosocial support related to her recent incident with a female peer (Resident #10). The resident was resting comfortably and was offered a stop sign velcro attachment to her doorway to prevent the female resident from wandering into her room. She was comfortable with that addition and appreciated the visit with the SSD who came to see her twice today.The 4/5/26 nurse note revealed that the director of nursing (DON) was notified that Resident #14 was having a visit from the police department and per the police, Resident #14 would file an assault case against Resident #10. Resident #10 was also questioned by the police with the presence of CNA #6.D. Staff interviewsCNA #6 was interviewed on 5/14/26 at 2:51 p.m. CNA #6 said Resident #21 (Resident #14's roommate) alerted her (on 4/2/26) that Resident #10 came into their room and was throwing things at Resident #14 and needed help. CNA #6 said she went into Resident #14's room and assisted Resident #10 out of the room. CNA #6 said Resident #14 always had packages and things on her bedside table and Resident #10 took those and was throwing them at Resident #14. CNA #6 said she found a mess of things on the floor. CNA #6 said that Resident #10 was just laughing at Resident #14 as she threw things at her. CNA #6 said that Resident #14 could not physically get out of bed or defend herself and was yelling out to stop hitting her and throwing things. Licensed practical nurse (LPN) #1 was interviewed on 5/14/26 at 3:00 p.m. LPN #1 said on 4/2/26 she was coming out of the medication room around 9:30 p.m. when she heard a commotion coming from Resident #14's room and CNA #6 got there first. LPN #1 said when she entered the room it was really a mess with products, boxes and items on the floor. LPN #1 said Resident #14 told her that Resident #10 had come into her room and started throwing things at her and a box or something hit her on the back of the head. LPN #1 said Resident #10 was assisted back to her room. LPN #1 said she looked at Resident #14's head and did not find any bump or cuts. LPN #1 said they put a stop sign up over the door to keep Resident #10 from coming in. LPN #1 said another time, Resident #10 had tried to throw a fire extinguisher at her unsuccessfully because it was too heavy but Resident #10 did throw a hair brush at her. The NHA, the DON and the regional clinical resource were interviewed together on 5/14/26 at 3:16 p.m. The DON said she had conducted the initial investigation for the 4/2/26 incident and at that time, Resident #10 had made contact with Resident #14 by throwing objects at her. The DON said that Resident #14 said she got hit in the back of the head but at the time they could not find any injuries, such as a bump or a cut, although the next day she had a slight headache the resident did not want ice or pain medication for.The DON said sometimes an incident was documented in the progress notes, which could be helpful for the staff to know what was occurring with the residents. She said the staff completed a shift to shift report to find out what was happening with the residents. The DON said they would also do a huddle meeting at 8:00 a.m. each morning and an IDT. The regional clinical resource said the progress notes would come through the risk management assessment if there was an allegation of hitting or something. The regional clinical resource said the facility completed an every shift psychosocial monitoring and behavior monitoring for the alleged assailant. The regional clinical resource said in addition, the residents would be on alert charting that would be put in after an incident happened to monitor for 72 hours. The regional clinical resource said that there was no progress note for Resident #14 detailing the incident on 4/2/26. The regional clinical resource said the nurse had entered the risk management incident under details, it would usually go under action in the risk management system which was the recommended section. The regional clinical resource said putting the risk management note under the action section would trigger a progress note in the resident's record. The regional clinical resource said she would conduct an education on that for the nurses to chart the risk management note in the proper section. The DON said Resident #14 had moved rooms in order to move in with her husband. The DON said the new interventions for Resident #14 after the 4/2/26 incident were to put a stop sign in front of the door and 15-minute checks. The DON said she thought Resident #10 followed Resident #14's husband back to the room and that was how she found out where Resident #14 lived. The DON said the plan to help Resident #14 feel safe from Resident #10 coming into her room was to put up a stop sign at her new room, do extra checks and nurses putting in progress notes. The DON said she would also update Resident #14's care plan to include to redirect Resident #10 away from her.The SSD and the social services resource were interviewed together on 5/14/25 at 4:44 p.m. The SSD said she had spent some time with Resident #14 last evening (5/13/26) and they had discussed her transition to a new room, new hallway, new staff, and her new roommate, her husband. The SSD said she realized last evening that when Resident #14 had transferred to her new room, the stop sign had not been put up at her new room. The SSD said at first it seemed Resident #14 did not want a stop sign, but now that she was aware that she did want it, they did put one up today. The SSD said Resident #14 was agreeable to counseling and she would get that set up and it would start in about a week. The SSD said they wanted Resident#14 to feel safe and the staff would be committed to that. The SSD said she would go talk with Resident #14 today and find out best re-direction technique, how stop sign in place was going, and talk with husband or both of them about Resident #10. The SSD said the social services staff would also be meeting weekly with Resident #14 to provide support.

Based on observation, record review, interview, and policy review, the facility failed to 1.) maintain a comfortable temperature for residents in their rooms and hallway for two of three units (West unit and the East unit), and 2.) maintain the residents' wheelchairs in a condition that was in good repair. Specifically, the wheelchair arms for seven of 78 residents' wheelchairs (Resident (R) 64, R239, R8, R240, R1, R118, and R117) were cracked and missing vinyl exposing the white material underneath. This failure prevented the cleaning and sanitizing of the wheelchair arm rests. Findings include: 1. a. Interview on 09/23/24 at 12:03 PM, R24 stated that her room gets hot and that she needs to use her fan. She stated that the room is not air conditioned (AC) and that the AC was in the hallway. Review of R24's electronic medical record (EMR) Care Plan tab revealed R24's annual Minimum Data Set (MDS), with an assessment referent date of 06/20/24, indicated a Brief Interview of Mental Status (BIMS) score of 14 out of 15, indicating the resident's cognition was intact. b. Interview on 09/23/24 at 12:11 PM, R1 stated that her room was hot, and she has to use her fan. Review of R1's EMR Care Plan tab revealed a quarterly MDS, with an ARD of 08/22/24, which indicated a BIMS score of 15 out of 15, indicating the resident's cognition was intact. c. Interview on 09/23/24 at 1:30 PM, R40 stated that it was very hot in her room last night. Review of R40's EMR Care Plan tab revealed a quarterly MDS, with an ARD of 07/25/25, which indicated a BIMS score of 15 out of 15, indicating the resident's cognition was intact. d. Review of R94's admission MDS, with an ARD of 07/23/24 and located in the resident's EMR section titled MDS, documented that the resident was cognitively intact and able to make decisions for herself. Observation on 09/23/24 at 11:15 AM revealed R94's room was stifling hot. There was no air coming from the air conditioning vents. During an interview with R94 on 09/23/24 at 1:30 PM, the resident stated that her room was hot as hell. R94 noted that she had complained several times to the staff and the Administrator, but nothing was ever done. Interview with the Director of Nursing (DON) on 09/23/24 at 1:42 PM, the DON stated the rooms do not have AC in them and that the hallways have the AC. Interview with the Maintenance Director on 09/23/24 at 2:43 PM, he confirmed that the residents' room do not have AC and that the AC was in the hallways. The Maintenance Director stated that when he checks the residents' hot water temperature in their bathrooms, he notices if the rooms are hot. He stated that he does not have any documentation of checking the residents' ambient room temperatures. During an interview on 9/24/24 at 11:10 AM, Certified Nursing Aide (CNA) 5 revealed the night shift usually turned the heat on at night because it was too cold, and the day shift must turn the heat off in the morning. During the tour of the residents' rooms throughout the facility and the thermostats on each hallway at 09/25/24 at 4:30 PM, the following observations were made of the thermostats. Observation on the [NAME] unit of the thermostat near room [ROOM NUMBER]B, revealed it was turned off. The Maintenance Director stated when the thermostat is turned off, there is no AC in that hallway and that causes the rooms on that hallway to feel warm. When the Maintenance Director turned on the thermostat and the AC came on, the hallway was 79.0 degrees Fahrenheit (F). Observation on the [NAME] unit of the thermostat in the hallway outside of the beauty shop, revealed it was turned off. When the Maintenance Director turned on the thermostat and there was AC, the temperature in the hallways was 77 degrees F. Observation of the East unit nurses' station revealed the thermostat was turned off, and when the Maintenance Director turned on the thermostat and there was AC, the temperature was 75.0 degrees F. Review of the facility's policy titled, Safe and Homelike Environment, dated 2024 and provided by the Administrator indicated, . 7. The facility will maintain comfortable and safe temperature levels. a. The facility should strive to keep the temperature in common resident areas between 71 and 81 degrees F . 2. During the tour of the facility on 09/25/24 at 4:30 PM, the following observations were made of the residents' wheelchair arm rests: R64, R239, R8, R240, R1, R118 and R117's wheelchair arm rests were cracked, exposing the white material below. Interview with the Maintenance Director on 09/25/24 at 4:53 PM, he stated that the Rehabilitation department or restorative nursing was responsible for the replacement of the damaged wheelchair arm rests. Review of the facility's policy titled, Wheelchair Management, dated 03/2024 and provided by the Administrator, indicated, . 5. The facility will maintain the wheelchair by providing maintenance as needed .

Based on observation, interview, record review, and review of facility policy, the facility failed to secure one of two medication carts on the East Wing when out of the site of the nursing staff. This failure could permit individual unauthorized access to residents' medications. Findings include: A review of a facility document titled, Medication Access and Storage, E kit access, with a revision date of 04/2024 read in part, Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Observation on 09/25/24 at 4:47 PM revealed the medication cart on the East wing was left unlocked at the nurses' station. There were no staff members present at the nurses' station. Residents (R) 8 and R22 were around the unlocked medication cart. R8 sat in a wheelchair across from the cart, and R22 propelled herself up next to the cart. Registered Nurse (RN) 3 returned to the unit and went to the bathroom. RN3 returned to the nurses' station and started talking to another staff member. R22 remained close to the unlocked medication cart. RN3 obtained a drinking cup from the cart and went into the medication room. The medication cart remained unlocked. RN3 returned carrying a drinking cup with clear liquid and gave it to R22. RN3 then briefly returned to the nurses' station without locking the medication cart. RN3 then got up pulled the medication drawer open and started to set up evening medications. The medication cart was unlocked for seven and one-half minutes. A review of R8's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/23/24 and located in the resident's electronic medical record (EMR) under the MDS tab, revealed R8 had severely impaired cognition. A review of R22's quarterly MDS, with an ARD of 07/09/24 and located in the resident's EMR under the MDS tab, revealed the resident's cognition was intact and was able to make decisions. An interview on 09/25/24 at 5:10 PM with RN3 revealed that she did not realize that she had left the medication cart unlocked. RN3 stated that she had left the unit to escort a resident to the dining room. RN stated that R22 was alert and oriented and was waiting for her evening drink. RN3 acknowledged that R8 was cognitively impaired and did not think that the resident could propel herself over to the medication cart. An interview was conducted on 9/25/24 at 5:30 PM with the Unit Care Coordinator Licensed Practical Nurse (LPN)1. LPN1 stated it was an expectation that the medication would always be kept locked when not in use. LPN1 stated it did not matter whether a cognitively intact or cognitively impaired resident was in the area; an unlocked cart would be a safety issue.

Based on record review and interview, the facility failed to ensure two of two residents and their representatives (R) 86 and R109) reviewed for facility initiated emergent hospital transfer from a total sample of 31 residents were provided with written transfer/discharge notices that contained the required information. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and how to notify the State Long-Term Care (LTC) Ombudsman's office. Findings include: 1. Review of R86's electronic medical record (EMR) Progress Notes in the Progress Notes tab revealed, . 03/11/24 at 3:48 AM, Resident . reported that he wasn't feeling well . BP [blood pressure] was 123/72, HR [heart rate] 132 Temp [temperature] 101.3 O2 [oxygen] 75% on 5L [5 liters] resp [respirations] 28 . orders to send to ER [emergency room ] . Paramedics took resident to [hospital] . Review of R86's EMR Progress Notes in the Progress Notes tab indicated, . 03/13/24 at 11:32 PM, res [resident] back from the hospital . 2. Review of R109's EMR Progress Notes in the Progress Notes tab indicated, . 08/03/24 at 5:27 PM, Suprapubic catheter continues to leak . paramedics contacted to transfer patient to ER for replacement . EMT [Emergency Medical Technician] here at approximately 6:30PM to take patient to ER . Interview on 09/25/24 at 2:01 PM, the Director of Nursing (DON) stated that when residents are discharged to the ER, the nurses send the Medical Orders for Scope of Treatment (MOST), Power of Attorney (POA) document, and face sheet with the resident, and if staff have time, they would print the transfer form, labs pertinent to the situation, and progress notes. Interview on 09/25/24 at 3:10 PM, the Social Service Director (SSD) provided the list of transfers that were sent to the State LTC Ombudsman's office. The SSD confirmed that neither R86 nor R109's hospital transfers were included on the list. The SSD stated that only transfers to home or death were sent to the State LTC Ombudsman's office. Interview on 09/25/24 at 5:00 PM, the DON provided a copy of R86 and R109's Transfer Form that was sent with the residents at the time of their transfer to the hospital. The DON reviewed the document and confirmed that neither transfer document included the resident's appeal rights nor the information regarding the State LTC Ombudsman office. The DON confirmed that the facility did not have a policy regarding facility initiated transfers and notification of the State LTC Ombudsman's office.

Based on observations, interviews, record reviews, and review of facility policy, the facility failed to 1.) follow current standards of practice related to the use of personal protective equipment (PPE) with transmission-based precautions and/or implement their policy and procedures related to enhanced barrier precautions (EBP) for two of two residents (Resident (R) 107 and R389) reviewed for transmission-based precautions out of a total sample of 31, and 2.) sanitize glucometers in a manner that prevented cross-contamination for one of three residents (R76) observed receiving fingerstick blood glucose tests (FSBG). These failures had the potential to lead to the spread of infection throughout the facility. Findings include: Review of the facility's policy titled, IPCP Standard and Transmission-Based Precautions, revised 03/2024, revealed, Droplet Precautions (TBP) are used for patients known or suspected to be infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking (e.9. influenza). Implement source control by placing a mask on the patient. Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives. Use personal protective equipment (PPE) appropriately. [NAME] mask (and eye protection if indicated) upon entry into the patient room or patient space. Limit transport and movement of patients outside of the room for medically necessary purposes. If transport or movement outside of the room is necessary, instruct patient to wear a mask and follow Respiratory Hygiene/Cough Etiquette. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on Transmission Based Precautions (TBP). Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) ii. For Enhanced Barrier Precautions, signage should also clearly indicate the high-contact resident care activities that require the use of gown and gloves b. Make PPE, including gowns and gloves, available immediately outside of the resident room, or for EBP gown and gloves can be available inside the room to promote dignity and quality of life. c. Ensure access to alcohol-based hand rub d. Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room e. Provide education to residents and visitors as needed. A review of the undated facility's document titled, Glucometer Disinfection, reads in part . create a clean . perform hand hygiene . disinfect the glucometer for with Micro kill disinfectant wipes for one minute . actively wipe the machine for one minute and let the glucometer air dry on a clean surface . 1. Review of R389's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated the resident was admitted to the facility from the hospital on 09/20/24 with diagnoses including malignant neoplasm of main bronchus, chronic obstructive pulmonary disease, and irritable bowel syndrome with diarrhea. Review of R389's hospital's undated Discharge Notes, located in the EMR under the Miscellaneous tab, revealed the resident had tested positive for COVID-19 on 09/12/24. During the facility's initial tour conducted on 09/23/24 at 11:56AM, an observation was made of R389's room. There was a sign on R389's door, indicating the resident was on droplet precautions; instructing staff and visitors to wear N95 mask, gloves, gowns, and googles or face shield; and to keep door closed. During an observation made on 09/23/24 at 11:56 AM, R389's door was left open. During observations conducted on 09/23/24 at 12:25 PM, and 12:30 PM, Certified Nurse Aide (CNA) 1 was observed going into and out of R389's room without the appropriate PPE, except for a surgical mask. During an interview conducted with CNA1 on 09/23/24 at 12:31PM, CNA1 was asked what she was supposed to wear to go into R389's room. CNA1 responded, I normally just wear a mask. CNA1 was asked why R387 was on droplet precautions. CNA1 stated, I was told it was for COVID; guess I should have been wearing goggles and gown. During an interview conducted with the Administrator on 09/23/24 at 12:50 PM, the Administrator stated he would expect whoever enters an isolation room to follow the precaution signs. During an interview conducted with the Director of Nursing (DON) on 09/23/24 at 1:51 PM, the DON was asked what her expectations were of staff and isolation residents. The DON responded, Staff should be aware of who is on isolation and what PPE is supposed to be worn. During observations conducted on 09/24/24 at 9:52 AM, 11:04 AM, and 3:39 PM revealed R389's room was no longer on isolation. R389 was observed to have an indwelling urinary catheter. There was no PPE available, and there was no signage to indicate the resident was on EBP, as per the facility's policy. During an interview with LPN2 on 09/24/24 at 4:28 PM, LPN2 confirmed R389 was supposed to be on EBP, and that there was no PPE or sign on the door. During an interview with the Infection Preventionist (IP) on 09/24/24 at 5:00PM, the IP was asked if R389 was supposed to be on EBP. The IP confirmed that there was not an EBP sign or PPE on 389's door. The IP stated that it was her fault, that she forgot to hang the sign and PPE on the door. 25490 2. Review of R107's Face Sheet, located in the EMR under the Profile tab, revealed that R107 was originally admitted to the facility on [DATE] with the diagnoses that included chronic respiratory failure with hypoxia, anoxic brain damage, and muscle wasting. Review of R107's Physicians Order, located in the EMR under the Orders tab and dated 05/27/24, revealed, . on Enhanced Barrier Precautions . related to having a tracheostomy and gastrostomy tube. Review of the EBP sign located on R107's door revealed, . wear gloves and gown for the following high care areas dressing, bathing showering . Observation on 09/23/24 at 11:29 AM revealed CNA1 was already in the room providing incontinent care. CNA1 wore gloves but did not wear a gown as per facility policy related to EBP precautions. During an interview on 09/23/24 at 11:37 AM, CNA1 confirmed she was not wearing a gown while providing incontinent care to R107. CNA1 stated she did not don a gown because she was in a hurry. She stated she had received infection control training, and that the purpose of EBP is to prevent the spread of infections. 16752 3. An observation on 09/25/24 at 5:00 PM revealed RN3 preparing to perform a FSBG test on R76. RN3 did not disinfect the glucometer before using it on R76. Once RN3 obtained the blood glucose test, she returned to the medication cart, created a clean field, obtained a Micro Kill Germicidal wipe, and wiped the glucometer for ten seconds. She then started putting the glucometer back in the medication cart drawer, stopped and wiped the glucometer for a few more seconds, wrapped the glucometer in the Micro Kill Wipe, and placed the wrapped glucometer inside the medication cart drawer. An interview was conducted on 09/25/24 at 5:33 PM with RN3. RN3 stated that she disinfected the glucometer that morning after testing the resident's blood glucose, and the glucometer had not been used since that time. RN3 stated she did not see the need to disinfect the machine before the evening fingerstick blood glucose check. RN3 stated that she was unsure of how long the glucometer should be wiped down with the germicidal wipe. An interview with Unit Care Coordinator Licensed Practical Nurse (LPN) 1 was conducted on 09/25/24 at 5:53 PM. LPN1 stated it was an expectation that glucometers be disinfected before and after each resident use. LPN1 stated the nurse is expected to perform hand hygiene, create a clean field, and use the Micro Kill One Germicidal Wipe, wiping the machine down for a full minute, and then leaving the machine to air dry.

Based on interviews, record review, and facility policy review, the facility failed to ensure allegations of abuse were reported per the federal regulations to the Colorado Department of Public Health and Environment (CDPHE) within two hours of the facility being made aware of the abuse allegations for three of three residents (Residents (R) 61, R237, and R387) reviewed for allegations of abuse out of a total sample of 31. Findings include: Review of the facility's policy titled, Abuse: Prevention of and Prevention Against, revision date of 10/2022, revealed, . Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the facility and to appropriate State or Federal agencies in the applicable timeframes . and applicable regulations . 1. Review of R61's undated Face Sheet, located in the electronic medical record (EMR) under the Profile tab, indicated R61 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, anxiety disorder, and dementia without behavioral disturbance. Review of R61's quarterly Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ADR) of 08/22/24, revealed R61 had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review of the MDS indicated the resident did not exhibit any behaviors. Review of R61's Care Plan, dated 12/05/22, revealed R61. utilizes [medication name] for diagnoses of depression. She has times where she can have extreme mood fluctuations that can cause increased angry and tearfulness . Interventions included, . assist with a program of activities that is meaningful and of interest . assist to identify strengths, positive coping skills, and reinforce these . R61 had not been cared planned for behaviors, including making false accusations. During this surveyor's Resident Council meeting, conducted on 09/25/24 at 1:53 PM, R61 requested to speak with this surveyor privately when questioned if any of the staff make you feel uncomfortable. Upon the conclusion of the meeting, this surveyor met with R61 in private, on 09/25/24 at 3:08 PM. R61 stated that she had seen Certified Nurse Aide (CNA) 3 and CNA4 come out of her room, and when she went into her room, there was water all over the sink and floor. R61 stated she went back out to the hallway and yelled at CNA3 and CNA4 to please clean up their mess next time. R61 stated CNA3 yelled at her, Would you like for me to pee all over your sink, and you can clean that up? When questioned if R61 had reported this to the administration, she replied Yes. R61 was visibly upset and crying over the incident. R61 stated that she had reported this to Registered Nurse (RN) 4, who asked her what she wanted to be done and suggested they file a grievance. When asked if she recalled how long ago this happened, R61 stated she thought it had been a year or two ago. Review of R61's Grievance Report, provided by the facility, indicated the report was made on 08/26/23 at 1:00 PM. The detail description of concern documented, Resident stated she asked [CNA3] to clean up the water around the sink in her room after they used it and he turned around while she was in the bathroom and said, 'should I just pee all over your sink and floor, would you like that?' Resident said she was upset and asked him to leave. During an interview on 09/25/24 at 5:15 PM, the Administrator stated the incident had not been reported to the State agency. The Administrator was asked to review the initial report of the alleged incident. The Administrator stated, Just looking at the initial comments on the grievance report, it does appear to be an allegation of verbal abuse and should have been reported to the state. The facility reported the incident on 09/25/24 at 7:00 PM. 2. Review of R237's Profile tab of the EMR reviewed R237 was admitted to the facility on [DATE] and discharged on ,d+[DATE]. Review of R237's admission MDS, with an ARD of 04/15/24, revealed R237 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of the facility's investigative documentation revealed that on 07/20/24 between 12:00 AM to 2:00 AM, R237 did not recall the exact time, R237 stated that she thought she heard LPN3 down the hallway near the nurses' station state, Get out of my face or I will hit you. At 8:00 AM-8:30 AM, R237 informed the weekend supervisor, Registered Nurse (RN) 4 about the allegation of verbal abuse regarding the night nurse, LPN3. The Administrator reviewed the Colorado (CO) State Agency's (SA) website which indicated that the facility's Social Service Director (SSD) notified the CO SA on 07/20/24 at 11:35 AM and the Occurrence number was 24020432015. Interview on 09/26/24 at 01:43 PM, the SSD confirmed by looking at the CO SSA website that the allegation of verbal abuse was reported to the SA on 07/20/24 at 11:30 AM, which was three hours after R237 reported to staff the allegation of verbal abuse. 3. Review of R387's undated Face Sheet, located in the EMR under the Profile tab, indicated R387 was initially admitted to the facility on [DATE], with a readmission on diagnoses including vascular dementia without behavioral disturbance, cognitive communication deficit, and aphasia. Review of R387's admission MDS, located in the EMR under the MDS tab and with an ARD of 01/07/24, revealed R387's BIMS score was 00 out of 15, indicating the resident was severely cognitively impaired. Further review of the MDS indicated R387 was assessed as not exhibiting any behaviors. Review of R387's Care Plan, dated 11/09/23, indicated R387 was . at risk for worsening/impaired cognitive function/dementia or impaired thought processes r/t [related to] new environment and diagnoses of vascular dementia. [Resident name] at time will become agitated with staff's redirection for safety concerns. He can yell and cuss at staff . Review of the Facility Reportable Incident (FRI), dated 01/09/24 and provided by the facility, documented, . [CNA2] was coming down hallway and witnessed nurse shut her med cart and turned to resident stating 'stop spitting on the floor that's f**king nasty.' Upon further investigation other staff report that resident was going behind nurse station and [name withheld] was redirecting him. Resident became verbally aggressive with her and was calling her names such as 'bitch'. Further review of the FRI indicated the incident occurred on 01/08/24 at 8:00 PM and was submitted on 01/09/24 at 5:12 PM to the CDPHE. During an interview on 09/26/24 at 12:53PM, RN1 stated that she had not been in the facility at the time of the incident since it happened on night shift, but the incident had been reported to her on 01/09/24, the next day, at change of shift. RN1 stated CNA3 reported that Licensed Practical Nurse (LPN) 3 got into the face of R387 and yelled at him. RN1 stated she did feel this was an allegation of verbal abuse, so she immediately told LPN4, North Unit Manager. During an interview on 09/26/24 at 1:06 PM, LPN4, the North Unit Manager, was asked what she did when she was informed about R387's incident. LPN4 stated that she turned the grievance over to the Director of Nursing (DON) at that time, who was no longer employed at the facility. During an interview on 09/26/24 at 5:30 PM, the Administrator was asked if he was aware of the incident with R387. The Administrator stated he did not recall the incident but confirmed that the allegation of verbal abuse should have been reported immediately.

Based on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one of one resident (Resident (R) 121) reviewed for hospice in a total sample of 31 residents. This had the potential to cause unmet care needs for R121. Findings include: A review of R121's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with medical diagnoses including stage IV sacral pressure ulcer and osteomyelitis of the vertebra, sacral and sacrococcygeal area. A review of R121's Order Summary Report, located in the resident's EMR under the Orders tab, revealed the following order, dated 04/07/24: admitted to [Hospice Name Withheld] with diagnosis of Osteomyelitis of Vertebra, Sacral and Sacrococcygeal Region. A review of R121's EMR revealed a quarterly MDS, with an Assessment Reference Date of 06/18/24 and located in the MDS tab of the EMR, which documented the resident was receiving hospice services. A significant change in status MDS was not completed until 07/03/24. During an interview on 09/26/24 at 11:39 AM, the MDS Coordinator (MDSC) confirmed that since R121 was placed on hospice in April, a significant change assessment should have been completed at least two weeks later. The MDSC stated that she was on vacation during that period, and it was overlooked; however, the significant change MDS was completed in July.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for accidents remained free from accidents. On 7/7/23 Resident #2 sustained an arm fracture during a transfer by one certified nurse aide (CNA) using a sit to stand lift. Prior to the transfer, Resident #2 was not evaluated and was not deemed safe or appropriate for the use of sit to stand lift. The incident during transfer was not clearly communicated to the nurse and head to toe assessment was not completed. As a result, the resident's arm fracture went unnoticed for the next 48 hours. The next day on 7/8/23 the resident refused to be transferred with a sit to stand lift and stayed in bed more than usual. The facility staff used a Hoyer lift for resident transfers for the next two days, however, the nursing staff did not complete a full body assessment to identify the cause of resident's sudden decline. On 7/9/23 the arm fracture was confirmed by the x-ray technician and the resident was sent to the emergency room for treatment. Findings include: I. Facility policies and procedures The Safe Resident Handling/Transfers policy, no date, was provided on 9/6/23 by the nursing home administrator (NHA). The policy read: The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. Mechanical lifts may include equipment such as full body lifts, sit to stand lifts, or ceiling track mounted lifts. Two staff members must be utilized when transferring residents with a mechanical lift. II. Sit to stand lift manual The user manual for Stand Up Patient Lift RPS350-I was provided by the NHA on 9/6/23. In pertinent part read: The stand up lift may be operated by one healthcare professional for all lifting preparations, transferring from and transferring to procedures with a cooperative, partial weight-bearing patient. However, since medical conditions vary, (the manufacturer) recommends that the healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. The use of the patient lift by one assistant should be based on the evaluation of the healthcare professional for each individual case. Individuals that use the standing patient sling (the bottom edge of the standing sling is positioned on the patient's lower back) must be able to support the majority of their own weight, otherwise injury may occur. III. Resident status Resident #2, age 86, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, congestive heart failure, osteoporosis (was added to the electronic medical record of the facility on 7/9/23, after the incident), syncope and collapse. The 5/15/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 10 out of 15. The resident required extensive assistance of two people with all transfers and bed mobility. The resident did not display any behaviors and did not refuse the care. IV. Resident interview The resident was interviewed on 9/6/23 at 1:53 p.m. She said she was admitted to the facility for long term care and initially was working with therapy. She said she used to be able to ambulate with a walker and assistance of one person and she preferred that way to transfer. She said some time in June 2023, when she came back from the outside therapy provider, she was transferred by a CNA, whose name she did not recall. The resident said the CNA was using a sit-to-stand lift and was rushing with the lift. She said everything happened so fast and I was in such a shock. I heard a pop and I knew immediately that my arm broke, it hurt so much. The resident said she did not recall where her hand was at the time of transfer or what happened shortly after. She said the transfer was completed by a CNA who worked in the facility and she did not recall her name. She said she was no longer working with therapy as her arm had to heal. She was wearing a sling on her left arm. She said staff used a Hoyer lift for transfers to help her transfer to a wheelchair. V. Record review The comprehensive care plan for activities of daily living (ADLs) initiated on 5/19/23 and revised on 5/31/23 documented the resident required up to one staff maximum assistance with transfers -Contrary to the above MDS assessment that documented she required two people maximum assistance. -The resident's care plan did not mention that the resident was transferred with sit to stand lift prior to the incident on 7/9/23. -The resident's care plan was not updated after 7/9/23 to show the resident had a fractured arm and required Hoyer lift transfer. The care plan did not mention the sling that resident was wearing on her left arm and care that it required. The resident's evaluation for sit to stand lift was requested from the director of nursing (DON) on 9/7/23. The evaluation was not provided at the time of the survey on 9/7/23 or 24 hours after. According to the July 2023 medical administration record (MAR) the resident was receiving the following medications: -Calcium 600 with Vitamin D one tab once a day for supplement, starting on 5/11/23; and. -Evenity, 210 mg every month for osteoporosis, starting 5/11/23 and completing 8/31/23. Resident #2 was monitored for pain every shift. The highest level of pain was documented on 7/8/23 in the evening as 8 out of 10 and in the morning of 7/9/23 6 out of 10. The resident received Tylenol for pain which was effective. Timeline of the events 7/7/23 to 7/9/23 Review of the progress notes revealed the incident was documented for the first time on the evening of 7/8/23, approximately 24 hours after it occurred on Friday 7/7/23 as it was determined by staff interviews (see below). On 7/8/23 (Saturday) at 6:38 p.m. LPN #3 documented: Resident came up to this nurse during shift change and stated that she hurt her arm yesterday while at (outside therapy provider). This nurse spoke with (primary care physician, PCP) shortly after as he was in the facility. The PCP gave new orders to this nurse to order two view x-ray of the left shoulder. -At 7:04 p.m. the same LPN documented: This nurse went into the resident's room to ask her about the incident and get more information about her arm. This nurse asked the resident when she hurt her arm at the (outside therapy provider) or where? Resident stated: 'The girl that helps me stand up on the machine that goes under my arms was taken out and she was not careful with my arm and it pulled it up hard and heard a pop.' This nurse assessed the resident's arm and there is a large visible red and purple bruise to her bicept/tricep area. The nurse could not assess residents range of motion as she stated she has very limited range of motion to her upper extremities. Resident stated severe pain when the arm was tried to be extended. Resident received pain medication at bed time. On 7/9/23 (Sunday) at 6:49 p.m. (48 hours/two days after the incident) registered nurse (RN) #1 documented: Radiology tech notified this writer that resident has 'obvious' significant fracture to left shoulder and did not want to cause her more pain by attempting to get a visual of the ordered humerus. Resident denies having any pain to her elbow, only shoulder. Resident was sent to the emergency room for the evaluation. VI. Hospital Records On 7/9/23 at 7:02 p.m. Resident #2 was admitted to the emergency room and diagnosed with displaced left humerus fracture. The admission note on 7/9/23 read: per the patient's history, multiple days ago she was at her living facility being transferred back to her bed with a lift when she felt a sudden pain in her left shoulder. She reports that she heard a 'snap'. She states that since that time she had been having persistent severe left shoulder pain and she has not been able to move her left arm. ER imaging showed a left displaced humerus fracture. The results of the x-ray documented: displaced left femur fracture and severe degenerative and demineralization changes VII. Note from PCP/medical director The 8/6/23 note by a medical director read: Resident had a recent left humerus fracture. Event occurred with routine transfer with staff. She noted mild pain at the time but pain was more significant at a later time. The events noted by staff were confirmed by the resident. She has a diagnosis for osteoporosis and has been on medications to treat it. She is at high risk for fractures due to her osteoporosis and this type fracture is consistent with osteoporosis. VIII. Staff interviews LPN #1 was interviewed on 9/7/23 at 9:20 a.m. He said he worked with the resident on Friday night 7/7/23 from 6:00 p.m. to 6:00 a.m. He said the resident was at her baseline and she did not complain about pain. He said he did not receive any reports from the previous shift about falls or any injuries. He said pain in the shoulder was an ongoing complaint from the resident. Regarding transfers, he said all transfers with lifts including sit to stand lifts were completed by two staff members all the time. He said he assisted CNAs on many occasions with transfers. CNA #1 was interviewed on 9/7/23 at 10:50 a.m. She said she worked on 7/7/23 from 6:30 a.m. to 2:30 p.m. In the morning she received a verbal note from the nurse that Resident #2 had an appointment with an outside therapy provider. She and CNA #2 assisted Resident #2 by using a sit to stand lift. Resident #2 was fine, she told us to be careful with her left arm and she complained about that arm before. The CNA said she left the facility before the resident's return from the therapy. The next time she worked was on Saturday, 7/8/23 on the morning shift. She said Resident #2 stayed in bed for breakfast because her left hand hurt a lot. She said she made another attempt before lunch to offer the resident to get up from bed, but the resident continued to say that her arm hurt. She was pointing at her arm and she said yeah it hurt. CNA said she came back later with another CNA and they transferred the resident to a wheelchair with a Hoyer lift. She said the resident kept saying they did something to my arm, but she would not say who did what. She said she did not recall talking to the nurse why she was using the Hoyer lift instead of the sit to stand for the resident. She said she probably did talk to the nurse because as a CNA she needed approval from the nurse to use a lift on the resident who was not using lift before. She said all lift transfers were always completed by two staff members. CNA #2 was interviewed on 9/7/23 at 11:24 a.m. She said she was working in the afternoon of 7/7/23 and assisted the resident from the wheelchair to bed when the resident returned from the therapy. She said she operated the sit to stand lift by herself. She said it was a common practice. She said only the Hoyer lifts required two person assistance, and since the resident was transferred with the sit to stand lift she was the only CNA present during the transfer. She said at the time of transfer she used the sling that ended at the residents lower back (standing sling). She said the resident did appear tired at the time of the transfer. She said as soon as she started lifting the resident off the chair she heard a pop and the resident started to complain about pain in her arm. She said she lowered the resident back to her chair. The CNA stated I did not feel comfortable transferring her with the lift because of her pain. She said she asked another CNA for assistance and the resident was transferred without a lift. She said she reported the incident to the nurse on duty, LPN #2. She said later in the evening, she and LPN #2 assisted the resident with removing her blouse. She said the resident's arm appeared swollen but not bruised. LPN #2 was interviewed on 9/7/23 at 11:32 a.m. She said she was working a day shift on 7/7/23. She said Resident #2 had chronic shoulder pain and stiffness. She said that morning was the same as usual. She said she assisted the resident with putting on a sweater before the resident went to therapy. In the afternoon, she said she did not recall being notified about anything unusual during transfer. She said the resident's pain appeared to be ongoing and chronic and nothing out of the ordinary. LPN #3 was interviewed on 9/7/23 at 11:45 a.m. She said she was working a day shift on 7/8/23. She said she did not receive any report from the night nurse (who was an agency nurse) about Resident #2. She said later that day, Resident #2 approached her and asked her to look at her arm. She said the resident was not clear on when and how her arm got hurt. She said she understood that her arm got hurt when she was in therapy. LPN #3 stated she checked the resident's range of motion but was not able to do a full range of motion as the resident kept saying ouch, I can not do that. She said she did not look at the arm as the resident was dressed and she was at the nurses station. LPN #3 stated the resident's physician was walking by and she explained the situation. She said the physician ordered the x-ray. She said she placed the order for regular x-ray, not an urgent one, as this is how she understood the physician. LPN #3 said later that day she did take a look at the resident's arm. She said the resident's arm had extensive red to purple bruise extending over the bicep area and to the back of the arm. She said she was not able to visualize the entire bruise as the resident was guarding the arm and could not move it. She said she did not call the physician, but used the internal texting system (that facility was utilizing to communicate with physicians) to report the bruising. She said she did not recall getting any message or phone calls back. She said she did recall giving the resident Tylenol for pain that day. She said she documented her observations under nurse notes. She did not recall if vital signs were completed. She did not recall completing a full head to toe assessment. RN #1 was interviewed on 9/7/23 at 12:05 p.m. She said she was working from 6:00 a.m. to 6:00 p.m. on 7/9/23. She said the report she received from the previous nurse was that Resident #2 had shoulder pain that was more significant than normal, she was transferred and got hurt. She said she was having a lot of pain and we were waiting for x-ray. She said she did recall administering pain medications to the resident. She said the resident did not use the numeric scale for pain, she was moaning and saying it hurt. She said the radiology technician came around 5:00 p.m. and told her that the resident's arm looked injured. He said it was an obvious injury and the resident was in so much pain that he did not want to hurt her. She said she contacted a physician and called the ambulance to send the resident to the emergency room . She said she did not complete a full head to toe assessment since the incident was reported by the previous nurse, she assumed that full head to toe assessment was completed by the previous nurse. Occupational therapist (OT) #1 was interviewed on 9/7/23 at 12:30 p.m. She said she was working with the resident since she was admitted to the current facility. She said at the time of admission the resident was ambulating with one person's assistance. She said that was the most current recommendation until the incident with a broken arm. She said prior to the incident the resident was never evaluated for sit to stand lift and therapy was not aware the resident was transferred by sit to stand lift. She said the request for evaluation should come from the facility staff indicating the reason. She said therapy did not receive any request to evaluate the resident for transfers with a sit to stand lift. The DON was interviewed on 9/7/23 at 12:53 p.m. She said the facility conducted the investigation regarding this incident. She said the CNA was not found at fault as it was facility practice to use only one CNA for transfers using the sit to stand lift. She said when the facility policy referred to the lift, it was referring to Hoyer lift, not sit to stand lift. She said only who required the use of a Hoyer lift for transfers required two CNAs. She said the lift was inspected and was found to be in working condition. She said the medical director reviewed the resident's history and provided his note that the resident's fracture was consistent with osteoporosis. She said once the injury was identified the facility took appropriate actions such as calling the physician and receiving an order for an x-ray. The therapy consultant was interviewed on 9/7/23 around 2:30 p.m. in the presence of the DON and the NHA. She said the transfer by sit-to stand lift intended to remove 50 percent of weight bearing from the resident. She said weight or pressure were not applied to the upper body during transfers and therefore could not cause such injury. She said the fracture was pathological in nature. She did not comment on the absence of a sit to stand evaluation for the resident prior to the transfer. IX. Facility follow-up On 7/8/23 the NHA submitted additional information by email. Specifically, he provided supporting documents and pointed out that upon admission the resident had a diagnosis of osteoporosis and was receiving treatment for that. In addition, resident's x-ray report from the emergency roiagnom on [DATE] indicated that resident had severe degenerative and demineralization changes in her upper extremity and the medical director who was also resident's primary care provider, documented in his notes that fracture was consistent with osteoporosis. Supporting documents included a hospital note date 4/1/23 indicating that resident was transferred with sit to stand lift at that time. Additional information included supporting documents for all the above statements and was included in the record review.

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. This was evidenced by hazardous hot water temperatures in resident care areas on two of three units. Water temperatures in resident rooms and two shower rooms exceeded safe temperatures, creating the likelihood for serious harm/injuries if the situation was not corrected immediately. Findings include: I. Immediate jeopardy A. Situation for immediate jeopardy Excessively high water temperatures were discovered in several resident rooms. The facility did not have a system to quickly identify elevated water temperatures in resident rooms, did not measure shower room water temperatures, did not provide education to staff to adjust mixing valves in shower rooms, and did not accurately document resident room water temperatures in order to identify problematic trends and to review and analysis through the quality assurance performance improvement process. Notice of immediate jeopardy was given verbally to the nursing home administrator (NHA) on 3/29/23 at 10:45 a.m. followed up by an email copy of the written notice, that that record review and interviews during the survey investigation confirmed deficient practice for water temperatures exceeding safe levels. B. Facility plan to remove the immediate jeopardy situation On 3/29/23 at 2:18 p.m. the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: Corrective Action: -The faucet temperature in room [ROOM NUMBER] measured at 133F. The maintenance director (MTD); immediately adjusted the point of use ([NAME]) valve and the temperature was reduced to 107.9F. -Faucet temperature in room [ROOM NUMBER] measured at 121F. The MTD immediately adjusted the point of use ([NAME]) valve and the temperature was reduced to 108.4F; -Skin checks were conducted for residents in both rooms. No burns were identified; -The NHA completed a one-on-one training with the MTD on tracking and reporting findings of the water temperatures to the safety committee and the quality assurance and performance improvement (QAPI) committee; -The East shower room temperature was 140F. The MTD placed a mark on the valve to only adjust the shower to that mark. The temperature at the mark was 111F; -The West shower room temperature was 143F. The MTD placed a mark on the valve to only adjust the shower to that mark. The temperature at the mark was 108F; -The MTD educated West and East shower aides to not take the water temperatures above the mark and provided thermometers; -A plumber was contacted to place an inner cartridge that would restrict water temperatures utilizing a dial system; -A second plumber was contacted and an appointment was scheduled for 4/4/23 to assess installation of a centralized mixing valve; -Educate shower aides and occupational therapy (OT) how to check the water temperatures prior to giving a shower; -The MTD adjusted water temperatures in hot water heaters to 120F; -Five hot water heaters were identified and drained at the source; -A facility audit would be conducted to verify water temperatures in resident care areas; -Staff development coordinator (SDC) will educate facility staff on determining water temperature safety and reporting concerns with the water temperatures; -The MTD to conduct random audits of community shower rooms and resident room temperatures seven times a week for seven days, then five times a week for 30 days, then three times a week for 30 days, then once a week for 30 days. Further monitoring recommendations will be determined during QAPI; and, -The NHA will review results and report to QAPI. On 3/30/23 at 9:15 p.m. the following additions were made to the plan: -One-on-one education with the MTD to ensure out of range temperature water was documented and what corrective action was taken. This will be documented on the Chlorine Level and Water Temperature audit. All out of range temperatures will be reported to the NHA and/or the director of nursing services (DNS) immediately for staff direction. Water temperatures within the expected range (less than 120F for resident rooms and less than 100F in shower rooms) will be reported to the NHA, DNS via the safety committee/QAPI; -The shower aides were instructed to notify the NHA or DNS if the water temperature was too cold or too hot; -Nurse resources interviewed three identified residents who were known to potentially shower themselves independently; -Plumber completed installation of the inner cartridge that restrict water temperatures from exceeding 120F; -The MTD reduced hot water heaters utilized in resident care areas to 120F; -Hot water policy was updated to reflect monitoring of hot water temperatures below 120F; -Signage was updated in the community showers to reflect water temperature ranges; -The MTD will audit community showers and resident room water temperatures at random times of the day to confirm shower room temperatures were below 100F and resident rooms below 120F; and -If concerns were identified in resident rooms or shower rooms, follow up monitoring would be conducted at 30 minute increments until water temperatures were maintained at a safe level. C. Removal of immediate jeopardy The immediate jeopardy was removed on 3/30/23 at 9:15 p.m. based on the facility's plan of correction (see above). However, deficient practice remained at an E level; with a potential for more than minimal harm, pattern. II. Professional reference According to the U.S. Consumer Product Safety Commission (CPSC) regarding Tap Water Scalds, Document #5098, last reviewed 3/20/12, retrieved from https://www.cpsc.gov on 4/5/23,: All users are urged to lower water heaters to 120 degrees Fahrenheit. Most adults will suffer third-degree burns if exposed to 150-degree water for two seconds. Burns will also occur with a six-second exposure to 140-degree water or with a thirty second exposure to 130-degree water. Even if the temperature is 120 degrees; a five-minute exposure could result in third-degree burns. III. Facility policy The Hot Water Temperature policy, revised June 2016, was provided by the NHA on 3/27/23 at 5:41 p.m. It read in pertinent part, It was the policy of the facility to provide a comfortable environment for each resident. Water temperature checks would be conducted and recorded by the MTD on a monthly basis. Hot water maintenance for long term care facilities environment to be between 95 degrees Fahrenheit and 120 degree Fahrenheit. IV. Record review A request was made for maintenance records to show instances of resident bathing water temperature testing to unsafe temperature levels; including records showing monitoring, water temperature adjustment and correction to ensure water temperatures were safe for resident use. The maintenance records only showed corrected temperatures after the MTD had made adjustments to the faucet mixing valve which was intended to control water temperature at the faucet. Additionally, the MTD's water temperature tests only included a small sampling of tested water temperatures. The sample was never expanded when water temperatures were found to be at dangerous levels (see the MTD interview below). -Failure to track and thoroughly investigate facility wide fluctuations in resident use water faucets in resident rooms and in resident showers, put the resident at risk of sustaining serious hot water burns. Additionally, the facility failed to maintain accurate records of where fluctuating water temperatures occurred and then launch an investigation as to why water temperatures were randomly fluctuating without any manual adjustment of the faucets was careless and dangerous to the resident in the facility's care. The facility's actions were likely to eventually lead to a resident sustaining a serious water related burn. The facility failed to have a record of instances where the water temperature exceeded a safe bathing level of 100 degrees F (see professional reference above). V. Observations Water temperatures from random rooms were checked on 3/27/23 the findings revealed: -At 4:00 p.m., the temperature of the sink in room [ROOM NUMBER] was measured and found to be 133 degrees F. -At 4:57 p.m. the temperature was observed with the MTD. The temperature was 134.2 degrees F. The sink had an individual mixing valve. The MTD was observed using a screwdriver to loosen a screw on the mixing valve and moving the controller on the mixing valve until the temperature was at 107 degrees F. He then tightened the screw back up. -At 5:00 p.m. the East shower water temperature was checked with the MTD and the water temperature was 139 degrees F. -At 5:15 p.m. the West shower room water temperature was checked and was 140 degrees F. The MTD was brought to the shower room to confirm the temperature, and at that time it was 143 degrees F. Water temperatures from random rooms were checked on 3/28/23 at 5:30 p.m. The water temperature in room [ROOM NUMBER] was found to be 124 degrees F. The MTD was brought to the room and the temperature was checked again. At that time the reading was 139 degrees F. The MTD adjusted the mixing valve under the sink and tightened the screw to lock it in place at 111 degrees F. On 3/30/23 at 11:55 a.m. a resident was observed being assisted into the West shower room. Certified nurse aide (CNA) #5 was setting up the shower. CNA #5 said she was told she did not have to measure the water temperature anymore, they were already adjusted correctly. The CNA went ahead and measured the water temperature, which was 108 degrees F. She said that the temperature was too hot for that particular resident so she turned the temperature control valve. CNA #5 felt the water with her hand and then asked the resident to feel it. The CNA moved the water stream to the resident's hand and the resident exclaimed ouch and pulled her hand away. CNA #5 moved the water stream away from the resident and adjusted the temperature control valve a second time. The CNA again felt the water with her hand and asked the resident to feel it. The resident indicated the temperature was okay. The temperature of the water was checked at this level, and was found to be 93 degrees F. VI. Resident interviews Residents were identified by facility and assessment to be interviewable. Resident #97 was interviewed on 3/28/23 at 9:23 a.m. Resident #97 said when he showered the CNA would ask him what he needed help with, hand him a towel, and adjust the water for him. Resident #97 said while he was showering, he could turn the water as hot as he wanted. After the shower, the CNA would turn the water off for him or keep it running for the next resident. Resident #37 was interviewed on 3/28/23 at 9:25 a.m. Resident #37 said she showered independently at night and adjusted her own water temperatures. She said she just let staff know she was going to shower. VII. Staff interviews The MTD was interviewed on 3/27/23 at 4:54 p.m.The MTD said he took the temperatures of the water in the resident room sinks randomly; and only tested on e room temperature in each hall one time a week. The MTD acknowledged he did not expand testing when he found a water temperature at a level higher than acceptable for resident use. The MTD said he did not take the temperature of the shower rooms, as each shower faucet had a mixing valve which could be controlled by the CNAs or the resident. The MTD said the temperature could go up to 165 degrees F, as the boiler was set at 165 degrees F. The MTD said each sink in the rooms had an individual mixing valve due to a past incident of having detected Legionella in the facility's water. The MTD was under the understanding that the boiler temperature needed to stay set at 165 degrees F. The mixing valves were applied to the plumbing to control water temperature coming out of the faucet to be less than 120 degrees F. The MTD said he did not want the water at the sinks to be over 120 degrees F. The MTD said the shower rooms had an adjustable mixing valve, but there was no way to determine the actual water temperature without a hand held thermometer, as there was no thermostat gauge on the shower faucets. The MTD said when he checked the water temperatures in the resident rooms, he often found the temperature to be above the 120 degrees F. The MTD said when temperatures were above 120 degrees F, he would just adjust the mixing valve to under 120 degrees F, and he would record the corrected temperature. The MTD acknowledged he was not tracking or documenting the frequency of which the resident sink water temperatures need to be adjusted to maintain safe water temperatures of under 120 degrees F which he believed to be safe for resident use. The nursing home administrator (NHA) was interviewed on 3/27/23 at 6:00 p.m. The NHA said he was made aware of the higher temperatures in the individual resident room sinks and the shower rooms. The NHA said that the water temperature needed to stay at 165 degrees F, indefinitely to prevent a recurrence of the Legionella found in the building's plumbing back in 2021. CNA #1 was interviewed on 3/27/23 at 6:13 p.m. CNA #1 said prior to the resident using the water he adjusted the water temperature and tested the water on the sensitive skin on his own arm first. CNA #1 said he would then ask the resident to feel it.I was taught to do it this way in school. CNA #2 was interviewed on 3/27/23 at 6:14 p.m. CNA #2 said she did not give showers, but if an independent resident wanted to shower, she would give them a towel and open the shower room for them. The CNA said she would ask the resident if they need any help or need the shower turned on, and then would leave the shower room. CNA #2 said there was nothing to stop the resident from turning the shower all the way to hot. CNA #12 was interviewed on 3/27/23 at 6:15 p.m. CNA #12 said she started the shower with the temperature control knob in the middle and adjusted the water temperature according to the resident's preference. The CNA said if the resident was nonverbal, she would check the water temperature on her wrist first then on the resident and watch the resident's body language for comfort. The CNA said this was how she was taught by the facility's CNA mentor. Registered nurse (RN) #4 was interviewed on 3/27/23 at 6:25 p.m. RN #4 said she did not give showers, but believed there was a temperature gauge at the shower head. RN #4 said she would recommend the CNAs check the water temperature on the back of her wrist to adjust to the correct temperature. CNA #5 was interviewed on 3/28/23 at 11:24 a.m. CNA #5 said she turned on the water and tested it on her skin, and then asked the resident to feel it. If the resident was unable to communicate, she would look for a reaction if the water was too cold or too hot. She said there was nothing to stop the resident from turning the water hotter. RN #1 was interviewed on 3/28/23 at 6:30 p.m. RN #1 said she did not give showers; if she had to, she did not know how to adjust the temperature. The NHA was interviewed on 3/30/23 at 4:30 p.m. The NHA said he was not aware the MTD was not tracking the hot water temperatures and correction efforts to maintain safe water temperatures. 20287 41172 47818 47960 48112 48113

Based on record review and interviews, the facility failed to prevent a significant medication error for one (#85) resident of eight residents reviewed for medication errors out of 47 sample residents. The facility failed to ensure medications were labeled according to the physician's orders to prevent significant medication errors for Resident #85. On 1/6/23, the facility administered 65 mg of Methadone instead of 15 mg ordered on 12/2/22. After the incorrect dose was administered, the resident required Narcan (to treat narcotic overdose) to be administered and was sent to the emergency room . The medication error caused the resident to be upset; he rocked in his wheelchair, hyperventilated, yelled and cursed at staff. Findings include: I. Facility policy and procedure The Medication Errors and Adverse Reactions policy, revised January 2022, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed in pertinent part, medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order. II. Resident #85 A. Resident status Resident #85, age 73, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease, insomnia, congestive heart failure and peripheral vascular disease. The 3/7/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status score of 11 out of 15. He required one person assistance with toileting, personal hygiene and dressing. B. Record review The March 2023 CPO documented: -Methadone HCl concentrate 10mg/ml. Give 15 mg two times a day for chronic pain. Start 12/2/22. The care plan on 12/19/22 documented the resident had a care plan for chronic pain and required methadone for pain control. Interventions included : -Monitor/document for side effects of pain medication. -Monitor/record pain characteristics. -Monitor/record/report to nurse any signs or symptoms of non-verbal plain. -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, or withdrawal to care. -Report to nurse any change in usual active attendance patterns or refusal to attend activities related to signs and symptoms or complaining of pain or discomfort. The progress note 1/6/23 at 11:53 a.m. documented, resident was given 65 mg of methadone. Methadone order was verified noted ordered dose was 15mg. The progress note on 1/6/23 at 11:53 a.m. revealed that Narcan was administered. The note also revealed the resident was very upset about medication error and that narcan was administered. Resident was rocking in wheelchair and hyperventilating yelling and cursing at staff. Notified doctor at 10:30 a.m. and sent to emergency room for evaluation. The progress note on 1/6/23 at 6:49 p.m. revealed the resident returned from the emergency room . The doctor was notified and stated to hold methadone through tomorrow then resume. The progress note revealed that the resident was placed on observation for 1/7/23 and 1/8/23. The progress note revealed that there was an interdisciplinary team meeting on 1/9/23 at 3:37 p.m. documented, resident given dose of narcan and transferred to hospital as his request. He returned in early evening post monitoring. Resident medication bottle updated with dose change sticker. The DON provided a copy on 3/23/23 at 6:00 p.m. of the computerized training the nurse completed post-medication administration error and documentation that all medications were verified to confirm the label matched the physician orders. IV. Interviews The director of nursing (DON) was interviewed on 3/30/23 at 4:00 p.m. The DON said she was aware of the medication error. She confirmed that the medication bottle was mislabeled. She said all medications were double-checked to confirm the labels were correct. The DON confirmed that the nurse involved in the medication error completed training.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically the facility failed to: -Ensure holding temperatures were at appropriate temperatures; -Ensure proper food handling practices; -Ensure health shakes were dated when thawed; -Ensure artificial nails with polish were not worn by food worker; and, -Ensure meat was thawed correctly. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food-borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, The food shall have an initial temperature of 41 F (fahrenheit) or less when removed from cold holding temperature control or 135 F or greater when removed from hot holding temperature control. B. Ensuring holding temperatures 1. 3/28/23 Dinner meal On 3/28/23 at 4:43 p.m. the temperature for the pureed dessert was 52.5 degrees F. The pudding was in individual monkey dishes and were on a large tray. There was no mechanism to keep it cold. The dessert consisted of vanilla pudding, pie crust and milk. -At 6:49 p.m., the temperatures were taken after the last resident was served. The temperature were as follow: -Coleslaw that was in individual serving bowls was 44 degrees F. There was no mechanism to keep it cold. -Coleslaw which was in a clear measured container next to the serving line was 59 degrees F. The container had no mechanism to keep it below 41 degrees F. 2. Health shakes The health shakes documented to store frozen and to discard after 14 days when thawed. During the initial walk-through of the kitchen on 3/27/23 at approximately 7:50 a.m., the walk in refrigerator had a pan with approximately 12 thawed health shakes with no dates of when they were thawed. 3/30/23 -At 8:00 a.m., the refrigerator at the East nurse ' s station had 14 thawed shakes that did not have an expiration date written on any shakes. -At 10:21 a.m., the refrigerator at the East nurse ' s station had 14 thawed health shakes that did not have an expiration date written on any shakes. 3. Medication carts On 3/27/23 at 8:00 a.m., a medication cart was observed near the dining room. A yogurt was opened and did not have any mechanism to keep it cold. On 3/30/23 at 9:57 a.m., the container holding yogurt and health shakes on the nurse ' s medication cart for the East wing was observed. The container had an ice block on the bottom. The ice block was not solid. The temperature for the yogurt and shake was as follows: -The health shake was 60.6 degrees F; and, -The yogurt was 57.3 degrees F. A second nurse ' s medication cart for the East wing was observed. The yogurt was in a quarter pan, with no mechanism to keep it cold. There were two health shakes which were thawed and no date as to when it was thawed. The temperature for the yogurt and shake was as follows: -The health shake was 46.2 degrees F; and, -The yogurt was 66.3 degrees F. The nurse ' s medication cart for the West wing was observed. The yogurt and health shake was in a metal container. The temperature for the yogurt and health shake was as follows: -The health shake was 43.8 degrees F; and, -The yogurt was 50.3 degrees F. 4. Interviews Licensed practical nurse (LPN) #2 was interviewed on 3/30/23 at 9:57 a.m. The LPN said she did not know what the temperature of the health shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She said that the expiration date for the shake was the printed expiration date on the cartons, not the handwritten date. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. Registered nurse (RN) #2 was interviewed on 3/30/23 at 10:10 a.m. The RN said she did not know what the temperature of the health shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She said that the expiration date for the shake was 72 hours after the shake was placed in the refrigerator. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. LPN #5 was interviewed on 3/30/23 at 10:20 a.m. The LPN stated she did not know what the temperature of the shake and yogurt located on the medication cart should be. She did not have a thermometer on the cart or with her to check the temperature. She did not know that the shake was good for 14 days after the shake was removed from the freezer to the refrigerator or medication cart. The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said there should be a cooling mechanism for the health shake and yogurt located on the medication carts. The RD said food should be held at 135 degrees F and above for hot food, and 41 degrees F below for the cold foods. II. Ensure proper food handling A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Food employees shall clean their hands and exposed portions of their arms for at least 20 seconds and shall use the following cleaning procedure: Vigorous friction on the surfaces of the lathered fingers, finger tips, area between the fingers, hands and arms for at least 15 seconds, followed by; thorough rinsing under clean, running, warm water; and immediately follow the cleaning procedure with thorough drying of cleaned hands and arms.Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles after handling soiled equipment or utensils. B. Observations On 3/28/23 at 5:03 p.m., the dietary manager (DM) corrected the dietary aide (DA) #1 on how to handle the resident ' s plates when placing their meals on a meal tray. At 5:59 p.m. DA #1 continued to handle the resident ' s plate incorrectly by placing her fingers on the eating surface of the plate DA #1 had long artificial nails. At 6:04 p.m., DA #2 made several grilled cheese sandwiches. When the DA #2 sliced the sandwich, she placed her gloved hand over the cooked sandwich to cut it. She did not have clean gloves on as she had touched the stove handles, a cart and various other items in the kitchen. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said ready to eat foods should be handled with a utensil, or clean gloves. III. Fingernails A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Unless wearing intact gloves in good repair,a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. B. Observations On 3/30/23 at 4:30 p.m., DA #1 was observed to preparing tartar sauce into small individual containers. She had false nails which were approximately a half an inch over the nail bed with nail polish. DA #1 was not wearing gloves. She then proceeded to work the tray line with the resident meal plates and desserts. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 5:42 p.m. The RD said staff that handled food should have well-groomed nails to be consistent with Colorado retail food establishment regulations. He said if staff had artificial nails with nail polish then they needed to wear gloves. IV. Thawing meat A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf read in pertinent part, potentially hazardous foods (time/temperature control for safety foods) shall be thawed: A. Under refrigeration that maintain the food temperature at 41 F (5 C) or less; or B. Completely submerged and with packaging removed under running water: 1. At a water temperature of 70 F (21 C) or below, 2. With sufficient water velocity to agitate and float off loose particles in an overflow. B. Observation On 3/30/23 at approximately 6:45 p.m., there were four hamburger rolls that were five pounds each. They were sitting in a pan of water and only a small stream of water was running on the edge of the pan and not directly on the meat. C. Interview The registered dietitian (RD) was interviewed on 3/30/23 at 6:45 p.m. The RD said the meat was not being thawed correctly, and that it needed to be under running water. He asked the cook to put the thawed meat into the refrigerator. 48112

Based on 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 quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident safety. Findings include: I. Cross-reference citations Cross-reference F689: The facility failed to keep residents free from accident hazards for unsafe hot water temperatures. Cross-reference F880: The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for medication pass, housekeeping, and hand hygiene before meals. II. Facility policy The Quality Assurance and Performance Improvement policy, revised January 2022, was provided by the nursing home administrator (NHA) on 3/30/23 at 7:00 p.m. It read in pertinent part: The purpose of the QAPI plan and process was to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable, physical, mental, and social well-being. QAPI committee members include, the director of nursing services (DNS), the medical director, the NHA, the infection preventionist, and at least two staff members. The committee meets at least monthly or more often as the facility deems necessary. III. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent the repeat deficiency of F689 accident hazards cited previously on 3/24/22 at a G scope and severity, and F880 infection control cited previously on 7/28/21 at an L scope and severity, immediate jeopardy. During the recertification survey on 3/30/23, accident hazards were cited at an K scope and severity, at immediate jeopardy and infection control was cited at an E scope and severity. IV. Staff interview The NHA was interviewed on 3/30/23 at 8:48 p.m. He said the QAPI committee met once a month. He said the medical director, the pharmacist, and himself were always in the meeting. He said each department had their own target areas to address, and put a performance improvement plan (PIP) in place in areas that needed attention. He said the facility did not identify hot water temperatures and the maintenance director (MTD) did not bring it to their attention and the committee was unaware of the high temperatures. The NHA said the facility educated staff on the importance of hand washing and housekeeping roll in infection prevention. He said resident hand hygiene was very important. He said the staff had training in January 2023 after the new company took over. He said the facility used the cleaning supplies given to them from the vendor. He said the facility needed to be better at identifying failures.

Based on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of the State Agency in the facility. Findings include: I. Resident group interview The resident group interview was conducted on 3/30/23 at 3:00 p.m. The group consisted of five alert and oriented residents selected by the facility. All five residents (#61, #45, #72, #85 and #56) said they did not know where the facility posted information in regardS to State Agency contact information, nor did they know how to contact the States Agency. II. Observations Observations, on 3/30/23, throughout the building revealed there was no posting which informed resident's how to contact the State Agency.

Based on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to file and follow up on resient grievances related to: -Missing clothes and items; and, -Call light times. Findings include: I. Facility policy and procedure The Grievances policy and procedure, last revised in November 2022, was provided by the social services director (SSD) on 3/29/23 at 2:47 p.m. It read in pertinent part, It is the policy of this facility to establish a grievance process to: address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished (examples may include the behavior of staff and of other residents; and other concerns regarding their facility stay; Make prompt efforts to resolve grievances the resident may have. Ensure information regarding how to file a grievance is made available to the resident, either individually or through postings in prominent areas throughout the facility, and includes the name and contact information of who to file a grievance and policy. Resident and/or Resident Representatives have the right to file a grievance orally or in writing, the right to file grievances anonymously, and obtain a written decision regarding his or her grievance as requested. Copies of the Grievance Resolution Forms are available from the Social Services Designee or Grievance official and at designated locations throughout the facility. These forms are to be initiated when grievances are reported. The Grievance official or designee responds to the individual expressing the concern within (3) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. II. Grievances for missing clothes and items A. Resident interviews Resident #44 was interviewed on 3/27/23 at 11:43 a.m. Resident #44 said she was missing an item of clothing. The item was a blue hoodie (sweatshirt). Resident #34 was interviewed on 3/27/23 at 2:05 p.m. She said she had been missing a tall coffee mug since Christmas. She reported the missing item to staff but nothing got done about the situation. She said staff get into her drawers and move things around. Resident #97 was interviewed on 3/27/23 at 3:36 p.m. He said he was missing three items of clothing and he reported it to staff a week ago but they did not do anything about it. Resident #102 was interviewed on 3/27/23 at 3:36 p.m. he said he was missing a N95 mask and three pairs of socks. He said he wore shoes without socks because all of his socks were missing. He said he was missing fingernail clippers with traction on the handle. He said he reported it to staff and had not heard back. Resident #37 was interviewed on 3/28/23 at 9:42 a.m. She said she filed a complaint to staff about two Broncos jerseys that went missing. The facility gave them to another resident and never took them back from the other resident. She said the facility replaced them with new ones. She said she did not want new ones and wanted the old ones back. Resident #87 was interviewed on 3/28/23 at 10:22 a.m. She said she was missing catalogs, soda and perfume. Resident #29 was interviewed on 3/28/23 at 10:33 a.m. She said $60 or $70 dollars went missing the first night in the facility along with several other small items and she told people running the place but they did not do anything about it. Resident #4 was interviewed on 3/28/23 at 10:48 a.m. She said he was missing blankets and clothes. Resident #61 was interviewed on 3/28/23 at 11:34 a.m. She said she was missing clothes after they were sent to be laundered by the facility and never returned back. She reported it to staff and had not heard back. Resident #14 was interviewed on 3/28/23 at 1:05 p.m. She said she was missing clothes and little odds and ends. She said before Christmas, she took some of her property out of the facility due to it going missing and only had clothes at the facility she did not care about losing. C. Staff interviews The laundry service staff member/housekeeper (HSKP) #2 was interviewed on 3/28/23 at 11:20 a.m. HSKP #2 said it was the laundry services department to tag the property with the resident's name. If a clothing item came with no name, it was placed to the furthest left of the rack. At the time of the interview, HSKP #2 said there were seven unlabeled and unaccounted items of clothing on the rack that was just delivered. There have been times when a resident had lost their property because it was unlabeled, when that happens, the certified nurse aide (CNA) or resident complained verbally. Then the laundry staff let the resident describe the item to them and then they looked for it and if the item matched the description they gave the resident the item. The housekeeping and laundry manager (HLM) was interviewed on 3/28/23 at 11:34 a.m. The HLM said CNAs dropped off dirty laundry everyday and the laundry staff delivered clean laundry everyday, and at times laundry staff delivered two times a day. The CNAs brought the laundry to the dirty side, which typically were two barrels for each wing. The CNA tagged the laundry before it came down. When property came to the laundry department unlabeled, they asked the CNA staff if they recognized the item. If the CNA could not identify any of the unlabeled items laundry staff would then hold them for a week or two then if they were still unaccounted for, the clothes would go to the donation pile or the social services department. The HLM said sometimes they were told of missing clothes complaints verbally or the social services department provided a note. Typically they received three complaints a week for missing property. When a resident had lost clothing, a description of the clothes was requested. The HLM said the donation pile and unlabeled rack was checked to see if the clothing item was found. Lastly, if laundry staff find the item that matched the description, laundry staff would give the clothing item to the resident. If the clothing item was not found, laundry staff would allow the resident to pick something else out and or replace it for them. At the time of the interview, the HLM said the entire donation pile was developed from unaccounted and or unlabeled property, which had 75 items of missing clothing and the residents never seem to come look for their items. The social services director (SSD) was interviewed on 3/28/23 at 11:55 a.m. The SSD said when someone reports missing property anyone that was scheduled to work should fill out a concern form at the time it was reported and look for the item. If staff find the item they fill out the form and turn it in and give the resident the missing item. However, if staff could not find the missing item, they would turn in the grievance form to the SSD, in order for the facility to start an investigation. When a grievance was filed, the facility had five business days to respond to the resident but the facility preferred an immediate response. If there was no resolution within five days we go to the resident and verbally talk to them and give the residents updates on the progress; weekly or anytime they want an update. If the items were not found by the facility, the facility would offer to replace the item. -The statement made by the SSD related to the resident response timeline of five business days to respond to the resident was in contrast with the facility's grievance policy which read to provide a response within three working days (see grievance policy above). D. Record review The 3/26/23 nursing progress note documented that Resident #29 had reported hearing aides were missing. The nurse told the resident she would let the social service director know on 3/27/23. -It did not provide any further documentation if an investigation had been completed or the steps taken to resolve the resident's concern. The grievance forms and investigations were requested on 3/28/23, during the survey process. The facility was unable to provide grievances and or documentation that an investigation had been conducted to resolve Residents' (#37, #61, #34, #29, #102, #44, #4, #14 and #87) concerns for missing items. The facility provided two grievance forms and investigation documents for Resident #97. -The grievance filed on 3/27/23 at 1:00 p.m. read the resident was missing clothing items. The facility failed to provide a resolution related to the missing items. -The grievance filed on 3/29/23 at 12:20 p.m. read the resident was missing two pairs of black socks, one beige short sleeve shirt, black sweat pants and two pairs of gray briefs. The facility located one pair of black socks and postponed further resolution of inventorying clothing items in a black bag found at the time the grievance was filed. -The grievances provided by the SSD were filed approximately a week after Resident #97 voiced concerns to the facility as indicated in the resident's interview. The timeline of filing the grievances were in contrast with the facility's timeline of initiating a grievance at the time the resident first reported the concern as noted in the facility's grievance policy. -The grievance form was incomplete and did not provide a resident response to acknowledge receipt and or satisfaction of the resolution. III. Grievances related to call lights A. Resident interviews Resident #29 was interviewed on 3/27/23 at 10:24 a.m. She said that she activated her call light but had to wait a long time. Resident #44 was interviewed on 3/27/23 at 11:45 a.m. She said the staff did not answer the call light. The other residents or a roommate would go and get the staff to help her. She said sometimes it takes quite a while for the facility to respond, everyday the response time was typically 30 minutes. Resident #34 was interviewed on 3/27/23 at 2:07 p.m. She said when another resident showered, residents were told by staff that they were not allowed to push the call button because staff were busy and if the residents pushed the call light, they would make residents wait for a long period of time. Resident #114 was interviewed on 3/27/23 at 4:01 p.m. Resident #114 said there were long waiting times with call lights. Resident #27 was interviewed on 3/27/23 at 4:20 p.m. Resident #27 said there were long call light times. Resident #82 was interviewed on 3/28/23 at 8:50 a.m. Resident #82 said the facility had long wait times on call lights. Resident #37 was interviewed on 3/28/23 at 9:42 a.m. She said call lights sometimes took two hours to respond and she was always up at the nursing station yelling at the staff and giving them a hard time because either there was no one at the desk or they were at the desk ignoring us. Resident #87 was interviewed on 3/28/23 at 10:22 a.m. Resident #87 said it takes the staff awhile for staff to respond to call lights. Resident #4 was interviewed on 3/28/23 at 10:49 a.m. Resident #4 said it depends on who was working to answer call lights but sometimes he had waited 45-60 minutes for help. Resident #45 was interviewed on 3/28/23 at 11:04 a.m. Resident #45 said it took 30 minutes at night for staff to respond to call lights, especially between 2:30 p.m. to 10:30 p.m. Resident #85 was interviewed on 3/28/23 at 11:32 a.m. Resident #85 said call lights take too long for them to show up. Resident #61 was interviewed on 3/28/23 at 11:34 a.m. She said there were not enough staff, a year and a half ago it was different. The good staff were no longer at the facility. She had a few accidents because of a delayed response by staff when she had to use the bathroom a few times. C. Record review The call light record revealed the following: For room [ROOM NUMBER]: -3/26/23- 44 minutes. For room [ROOM NUMBER]: - 3/20/23 - 41 minutes; and, - 3/25/23 - 35 minutes. For room [ROOM NUMBER]: -3/21/23 - 42 minutes; and, -3/24/23 - 37 minutes. For room [ROOM NUMBER]: -3/19/23 - more than 30 minutes; -3/20/23 - more than 30 minutes; and -3/24/23 - more than 30 minutes. For room [ROOM NUMBER]: -3/21/23 - 95 minutes (one hour and 35 minutes). D. Staff interview The director of nursing (DON) was interviewed on 3/30/23 at 3:20 p.m. She said that the call light system was only available on a desktop computer located in her office. She said the call light logs were not regularly reviewed. 20287 47818 47960 48112

Based on observations and interviews the facility failed to ensure two out of three medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional principles. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was secured to the refrigerator; -Ensure medication room door was locked; -Ensure medication cart was locked when nurse not at the cart; -Ensure alcohol for drinking was not stored with used culture vials; -Ensure batteries and medications were not stored together; and, -Ensure controlled medications for disposal were kept in a double locked area until disposal. Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, dated January 2021, was provided by the director of nursing (DON) on 3/29/23 at 4:35 p.m. It read in pertinent part, Controlled medications requiring refrigeration are stored within a locked, permanently affixed box within the refrigerator. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets and medication supplies should remain locked when not in use or attended by persons with authorized access. Potentially harmful substances (such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications. III. Observations and interviews On 3/27/23 at 8:33 a.m., a medication cart on the north 900 hall was observed to be unlocked and the nurse was not within direct line of sight with the cart for several minutes. When the nurse returned, she was notified that she left the medication cart unlocked and she said I know, I just went to get some ice. The ice machine was located around the corner down a separate hall. At 8:52 a.m. the medication room on the north unit was not locked, there were not any nurses nearby, the box storing the refrigerated controlled medications was not permanently affixed inside the refrigerator, and the refrigerator was not locked. At 1:30 p.m. the medication room on the north unit was still unlocked. At 5:00 p.m. the medication room on the north unit remained unlocked. On 3/28/23 at 8:30 a.m. the medication room on the north unit was unlocked. At 1:00 p.m. the medication room on the north unit was unlocked. At 6:00 p.m. the medication room on the north unit remained unlocked. On 3/30/23 at 1:14 p.m. the west medication room was observed. A COVID swab vial, marked with date collected and residents name, was in the refrigerator used to store resident alcohol, batteries were stored in the medication refrigerator and the controlled medication box was not permanently affixed to the refrigerator. On 3/27/23, 3/28/23, 3/29/23 and 3/30/23 observations of the director of nursing (DON) office revealed she was often out of her office and her office door remained open, leaving the controlled medications only in the single locked metal filing cabinet. IV. Administrative interviews The director of nursing (DON) was interviewed on 3/30/23 at 11:00 a.m. She said she took the controlled medications from the medication carts and medication rooms when they were no longer in use. She put them in a locked filing cabinet in her office and her office door locked. The DON acknowledged none of the medication refrigerators were locked.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure staff used proper hand hygiene; -Ensure residents were provided with an opportunity to participate in hand hygiene prior to meals; and, -Ensure residents' personal property were labeled and stored appropriately. Finding include: I. Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 2/21/23 revealed, in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 4/10/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas ( patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services Infection Control policy and procedure, last revised in January 2009, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites. Frequent cleaning of the facility's interior will aid in physically removing and reducing microorganisms' potential contribution to the incidence of health-associated infections (HAI); The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness; Periodic inspection of the facility will be made by the housekeeping supervisor or as a joint exercise with the infection control team; Cleaning shall be performed in a manner to minimize the spread of pathogenic organisms;dust high places before dusting lower areas light fixtures, tops of closets, tops of door casings, window coverings, TV's (televisions), pictures and other wall hangings tables, beds, medical apparatus, window sills; straighten displayed resident personal belongings (no gloves on); Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; door knobs, TV remotes, bed controllers, phones, bed-side tables, light switches,closet doors/dresser drawers medical apparatus like oxygen concentrators, clean heavily soiled restroom fixtures and porcelain surfaces using disinfectant and a rag or brush clean restroom walls with disinfectant; clean mirror with glass cleaner; Wipe down with disinfectant soaked rag all touched surfaces in room, allow to air dry; remove trash and re-line the receptacle, clean the receptacle as needed using disinfectant to disinfect sweep entire room including under beds;mop floors with dispensed solution of floor cleaner. C. Manufacturer recommendations The disinfectants in the facility were identified as: Comet Disinfectant-Sanitizing Bathroom Cleaner The product label was reviewed which read in pertinent part, Clean surfaces prior to disinfecting heavily soiled areas. For highly heavily soiled areas, clean before disinfecting following disinfecting directions. Thoroughly wet hard, non-porous surfaces with disinfecting solution for 10 minutes, then rinse or wipe clean. Spray the product on the surface and let stand for 10 minutes before wiping. Spic N Span -Disinfectin All-purpose Spray & Glass Cleaner Concentrated The product label was reviewed which read in pertinent part, to disinfect visibly soiled areas a preliminary cleaning is recommended. Spray 6-8 inches from hard, non-porous surfaces. Treated surfaces must remain visibly wet as indicated below.Wipe with a paper towel. Effective in 2 minutes against: SARS related coronavirus 2, Influenza A, H5N1, Respiratory Syncytial Virus, Human Coronavirus, Hepatitis B, Hepatitis C, HIV Type 1, Vaccinia Virus. Effective in 3 minutes against: Staphylococcus Aureus, Salmonella Enterica, Pseudomonas aeruginosa, MRSA, Norovirus, Rotavirus, E. Coli, Listeria Monocytogenes, Feline Calicivirus. Effective in 10 minutes against: Klebsiella Pneumoniae, NDM1, Acinetobacter baumannii, Enterobacter Cloacaen, Shigella Flexneri, Proteus Mirabilis, Candida Albicans and Candida Glabrata. D. Observations On 3/30/23 housekeeper (HSKP) #3 was continuously observed from 10:06 a.m. to 10:45 a.m. The observations showed the surface disinfectant time of the disinfectant was not ten minutes as indicated (see above). room [ROOM NUMBER] -At 10:06 a.m., HSKP #3 engaged in hand hygiene with sanitizer then wore gloves. -At 10:12 a.m., HSKP #3 wiped the sink and faucet with a disinfectant soaked wet wiping cloth for 39 seconds, the surface disinfectant time was not adhered to. -At 10:14 a.m., HSKP #3 did not disinfect high frequency touch areas (door handles, light switches and call lights). -At 10:20 a.m., HSKP #3 wiped a desk and a drawer for 11 seconds with a spic and span disinfectant soaked wiping cloth. -At 10:23 a.m., HSKP #3 wiped the bathroom rails with a different disinfectant soaked wiping cloth for five seconds. HSKP #3 wiped half the call light string in the bathroom. The call lights in the room by the bed were not disinfected. room [ROOM NUMBER] -At 10:25 a.m., HSKP #3 engaged in hand hygiene with hand sanitizer then wore gloves. -At 10:27 a.m., HSKP #3 sprayed disinfectant (comet) in the toilet and changed out all trash can liners. -At 10:28 a.m., HSKP #3 changed gloves and engaged in hand hygiene between switching from the wiping cloth to the broom. HSKP #3 swept the room and bathroom. -At 10:31 a.m., HSKP #3 wiped the sink for 23 seconds with a disinfectant soaked wiping cloth. The surface disinfectant time was not adhered to. -At 10:32 a.m., HSKP #3 wiped the desk for six seconds with a disinfectant soaked wiping cloth. The surface disinfectant l time was not adhered to. -At 10:35 a.m., HSKP #3 wiped the dresser for 13 seconds with a disinfectant soaked wiping cloth. The surface disinfectant time was not adhered to. HSKP #3 replaced her gloves and engaged in hand hygiene with sanitizer. -At 10:36 a.m., HSKP #3 wiped the bathroom rails first then the toilet. The surface disinfectant time was not adhered to. The total time elapsed from initial comet disinfectant spray was nine minutes.HSKP #3 scrubbed the toilet with a brush. The surface disinfectant time was not adhered to. -At 10:37 a.m., HSKP #3 wiped the toilet rim and water tank with a disinfectant soaked rag. The base of the toilet was not cleaned. HSKP #3 changed gloves after she cleaned the toilet and proceeded to grab a mop. -At 10:42 a.m., HSKP #3 mopped the floor with a disinfectant soaked wet pad. -At 10:45 a.m., HSP #3 completed the cleaning of the room. High frequency touch areas were not disinfected. HSKP #4 was continuously observed from 10:52 am to 11:05 am. room [ROOM NUMBER] -At 10:52 a.m., HSKP #4 changed her gloves and engaged in hand hygiene with sanitizer for eight seconds. -At 10:54 a.m., HSKP #4 sprayed the sink bowl with spic n span. -At 10:55 a.m., HSKP #4 sprayed the toilet bowl with comet. -At 10:56 a.m., HSKP #4 replaced the trash can liners in the room. -At 10:58 a.m., HSKP #4 changed her gloves and engaged in hand hygiene with sanitizer. HSKP #4 wiped the desk and drawer for 19 seconds with a disinfectant soaked wet wiping cloth. HSKP #4 replaced the disinfectant soaked wet wiping cloth with a new wiping cloth to begin cleaning the other side of the room. A desk and dresser were wiped for 10 seconds. The surface disinfectant time was not adhered to. -At 10:59 a.m., HSKP #4 wiped sink bowl within four minutes from the initial spray of spic n span. The faucets and countertop were wiped with a disinfectant soaked wiping cloth for 18 seconds. The surface disinfectant time was not adhered to. -At 11:01 a.m., HSKP #4 wiped the toilet with a disinfectant soaked wet rag within six minutes from the initial spray of comet and used a brush to clean the toilet bowl. The surface disinfectant time was not adhered to. -At 11:04 a.m, HSKP #4 wiped the bathroom hand rails for 17 seconds.The bathroom call light was not cleaned. The surface disinfectant time was not adhered to. -At 11:05 a.m., HSKP #4 did not disinfect high frequency touch areas (door handles, light switches and call lights). E. Interviews HSKP #3 was interviewed on 3/30/23 at 10:46 a.m. HSKP #3 said she used comet which had a 10 minute surface disinfectant time to clean the toilets and spic and span with a three to five minute surface disinfectant time, but was uncertain, for the sink and other areas. HSKP #3 said surface disinfectant time meant to use a soaked wiping cloth and just wipe the area and was unsure what high frequency touch areas were. She said she did not keep track of time for surface disinfectant times but she just did her cleaning process and enough time should pass for the surface disinfectant time after she completed other housekeeping tasks in the room. HSKP #4 was interviewed on 3/30/23 at 11:06 a.m. HSKP #4 said she used comet first and had to wait 10 minutes for it before she wiped it and then she used spic and span on all other surfaces by spraying the surface first then wiping it off shortly after with the rag. HSKP #4 said surface disinfectant times mean to spray the surface once and just wait 10 minutes for the comet but the spic and span could be sprayed and wiped after she was done brooming the room. HSKP #4 was unable to identify high touch areas. She said she did not keep track of time for the surface disinfectant times to ensure enough time has passed before she wipes the surfaces. The housekeeping and laundry manager (HLM) was interviewed on 3/30/23 at 1:48 p.m. The HLM said housekeeping staff should clean all the resident rooms daily. The process to clean the room was to start by emptying the trash and then use four rags per room. First, they start on the right and do light dusting (window sills, blinds, dresser, desk). Second, they should ring the rag and wipe surfaces, once done they change the rag and then go to the next side and wipe the mirror, counters, sink, paper towel and soap dispenser. Third, they check if there are paper towels and soap in there. Fourth, they go to the bathroom and wipe all the rails, toilet and inside the bowl with the brush. Lastly, they swept the floors in the room and bathroom then mopped after it and then wiped the window ledge. All high touch areas were not cleaned by the housekeepers and were cleaned by her and HSKP #2 which they try to get to every other day, however, housekeeping staff were expected to clean call lights,blinds, light switches, door knobs, closet doors and use a duster for the blinds. The HLM acknowledged cleaning methods observed were not correct with the facility's procedure and the surface disinfectant times were not followed. The infection preventionist (IP) was interviewed on 3/30/23 at 4:43 p.m. The IP said she was not involved yet with the housekeeping department in regards to infection control. The IP was unsure of the cleaning products used at the facility without observing a list of the cleaning products which had to be obtained from the HLM. The IP was unaware of the surface disinfectant times of the cleaning products used without asking the HLM. However, the IP said surface disinfectant times meant the surface must stay wet for the disinfectant time listed on the label of the disinfecting product; if the product did not stay wet for the time listed then the disinfectant would be ineffective. The IP identified high touch areas in the resident room as: over the bed table and everything on it, call lights, sink area, faucets, toilet area, everything the resident touched, grab bars, door knobs and light switches. II. Medication pass obervations Medication pass was observed on two units and infection control protocols were not followed. On 3/28/23 at 4:00 p.m. licensed practical nurse (LPN) #1 was observed for medication pass. One controlled medication was dropped onto the surface of the medication cart and it was not disposed of. Instead she picked up the medication and put it in the medication cup and proceeded to give it to the resident. At 4:02 p.m. LPN #1 was observed for medication pass. The LPN did not use hand sanitizer or wash her hands prior to donning gloves to administer eye drops. At 5:15 p.m. registered nurse (RN) #1 punctured the fingertip of a resident, she did not discard the first drop of blood and used that first drip as the collection amount to obtain the blood sugar reading. She used the same alcohol swab that was used to clean the residents fingertip to cover the bleeding after the collection was complete. On 3/29/23 at 12:20 p.m. RN #2 was observed for medication pass. She did not use hand sanitizer or don gloves after knocking on the residents door and opening the door to ask about the residents pain level. The RN went back to the medication cart to collect medications for the resident, placed them into the medication cup, picked up the cup and carried it back to the residents room and gave the medications to the resident without performing any hand hygiene. Prior to the nurse opening the residents door housekeeping did not sanitize any high touch surfaces such as door handles (see observations above). On 3/30/23 at 8:14 a.m. RN #2 was observed for medication pass. She used hand sanitizer but then pulled her sleeves down. III. Failed to ensure residents were provided with an opportunity to participate in hand hygiene prior to meals A. Professional reference The Centers for Disease Control (CDC) Hand Hygiene updated 2/7/23, retrieved on 4/11/23 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. Practicing hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate SARS-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% ethanol or 70% isopropanol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. B. Facility policy and procedure The Hand Hygiene Infection Control policy and procedure, last revised in October 2022, was provided by the NHA on 4/4/23 at 2:09 p.m. It read in pertinent part, Hand hygiene is one of the most effective measures to prevent the spread of infection. Studies show that effective hand decontamination can significantly reduce the rate of healthcare associated infection. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Hand hygiene should occur before and after eating or handling food. C. Observation The resident room meal trays were delivered on 3/29/23 at 5:45 p.m. to the West unit and residents were not offered or encouraged hand hygiene prior to eating their meal. -At 5:45 p.m., a certified nurse aide (CNA) delivered a room tray to room [ROOM NUMBER]B and did not offer hand hygiene to the resident. -At 5:47 p.m., a CNA delivered a room tray to a resident in room [ROOM NUMBER]A. She failed to offer hand hygiene to the resident. -At 5:50 p.m., a CNA delivered a room tray to a resident in room [ROOM NUMBER]A. No hand hygiene was offered to the resident. On 3/29/23 the dining room was observed continuously from 5:30 p.m. to 7:00 p.m. -At 5:45 p.m. meal trays were provided to residents, no hand hygiene was offered by staff. Hand hygiene products were not available on any trays. -At 6:25 p.m. all meal trays were provided to residents, no hand hygiene was offered by staff. Hand hygiene products were not available on any trays. -At 6:02 p.m. an unidentified kitchen staff member served one resident in the dining room. Hand hygiene was not offered to the resident. -At 6:26 p.m. residents in the dining room were being served dinner. Hand hygiene was not offered to residents in the dining room. -At 6:47 p.m. the last meal tray was provided to a resident. Hand hygiene was not offered to all residents in the dining room. C. Interview RN #5 was interviewed on 3/27/23 at 8:35 a.m. RN #5 said prior to eating, the resident should be provided hand hygiene. IV. Failure to label and store personal items properly A. Facility policy and procedure The Resident Personal Belonging policy and procedure, undated, was provided by the NHA on 4/4/23 at 2:09 p.m. It read in pertinent part, It is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident. All resident possessions, regardless of their apparent value to others, will be treated with respect. The facility will support the resident's right to retain and use personal possessions to promote a homelike environment and maintain their independence. All resident personal items will be inventoried at the time of admission by the social services designer, or another designated staff member and documentation shall be retained in the medical record. The facility will ensure resident belongings are kept in a neat and orderly fashion and maintained in each resident's room. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. B. Observations On 3/27/23 room at approximately 11:00 a.m., room [ROOM NUMBER] a shared room had a toothbrush and unmarked hair brush at the sink. On 3/28/23 at 9:52 a.m. room [ROOM NUMBER] had unmarked toothbrush and hairbrush in a shared room. At 12:44 p.m. an unmarked hairbrush and toothbrush were on the counter of room [ROOM NUMBER]. At 1:00 p.m. an unmarked toothbrush was at the sink. 3/30/23 -At 8:00 a.m. room [ROOM NUMBER] in a shared room had a hair brush and toothbrush was unmarked. -At 8:02 a.m. room [ROOM NUMBER] had a toothbrush laying directly on the counter. -At 8:15 a.m. room [ROOM NUMBER], had a toothbrush on the sink and was not marked in a shared room. C. Interviews The staff development coordinator (SDC) was interviewed on 3/30/23 at 3:40 a.m. The SDC said it was the CNA's responsibility to use a sharpie marker to label any resident's personal property including personal hygiene products and to put it in a plastic bag to store it. 40960 47960

Based on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#117) of three residents out of 47 sample residents. Specifically, the facility failed to: -Develop and revise a person-centered acute/baseline care plan within 48 hours of admission for Resident #117 that included pertinent healthcare information related to the resident's psychosocial needs, anxiety with depression, and history of trauma for staff to use to prevent potential further anxiety and retraumatization; and, -Review the baseline care plan with the resident or the resident's representative for input into choices and approaches. Findings include: I. Facility Policy The Baseline Care Plan policy and procedure, undated, was provided by the nursing home administrator (NHA) on 3/27/23 at 4:30 p.m. It documented in pertinent part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives. Interventions shall be initiated that address the resident's current needs including any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. II. Resident status Resident #117, age 68, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included traumatic brain injury, chronic pain syndrome and anxiety with depression. The 2/7/23 minimum data set (MDS) assessment indicated the resident had a moderate cognitive impaired with a brief interview of mental status (BIMS) score of nine out of 15. He required supervision of one staff member for bed mobility, transfers, dressing, and personal hygiene. He required limited one person assistance with toileting. According to the MDS assessment, Resident #117 had verbal behaviors directed towards others, rejection of care and symptoms of depression. He was on an antidepressant daily. III. Record review The 2/3/23 nursing admission assessment documented the resident was anxious and withdrawn at times. The baseline care plan, initiated 2/3/23, was reviewed. The care plan did not include the resident's depression, or any specific interventions related to Resident #117. -It did not include information from the resident's admitting nursing assessment on 2/3/23 (see above) about being anxious and withdrawn at times. There were no revisions to the baseline care plan during the resident's stay. There was no evidence the baseline care plan was reviewed with the resident or the resident's representative for input into what interventions would be helpful for the resident. The baseline care plan included that the resident was at risk for impaired cognitive function. The goal was that the resident would remain oriented to person, place, situation, time through the review date. A preprinted box of interventions was listed. The box next to communication was checked and documented, Identify yourself at each interaction. Face when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. (etcetera) Use simple, directive sentences. Provide with necessary cues- stop and return if agitated. -However, there were no specific person centered interventions for Resident #117 with his diagnosis of depression, or feelings of anxiety documented on his admission. The comprehensive care plan, initiated 2/3/23, documented the above cognitive function risk and the same interventions. It further documented Resident #117 was on an antidepressant and at risk for adverse effects. The goal was that he would be free of adverse reactions. The only intervention listed was to monitor for signs and symptoms of the side effects. -There were no further interventions to address his anxiety with depression. On 2/4/23 at 5:12 p.m. the nursing progress notes documented, Resident frequently refused CNA's (certified nurse aides) assistance throughout shift. Verbally aggressive towards staff. On 2/5/23 at 1:59 p.m. the nursing progress notes documented, new admit charting resident verbally aggressive with CNA's cussing and hollering at them, kicking CNA's out of the room. On 2/6/23 at 9:37 a.m. the skilled nursing notes documented the resident had refused therapy. On 2/6/23 the history and physical documented in pertinent part, Has significant mood disorder in addition to memory deficits. Since admission to SNF (skilled nursing facility) setting he has been highly resistant to cares and interventions including routine vital sign monitoring, routine therapy, is verbally aggressive at times. On 2/6/23 at 10:14 a.m. the nursing progress notes documented, Resident refused to have VS (vital signs) taken. Stated to CNA, 'Get . out of my room. 'When the provider entered, the patient refused to talk to him. Refusing care, refusing to be weighed. On 2/6/23 at 5:52 p.m. the nursing progress notes documented complaint of left sided neck muscle spasm and pain. Patient verbally aggressive and yelling at this nurse when offered Tylenol. On 2/7/23 at 11:46 a.m., the social service assessment documented, Currently he utilizes Venlafaxine (antidepressant) for diagnosis of anxiety/depression. Resident #117 reported feeling down depressed/hopeless, having trouble falling asleep, feeling tired, feeling bad about himself and moving/speaking so slowly that others may have noticed. Resident #117 reported 'experiencing trauma when in he was physically attacked by a (person of color) man at a store in Alaska in 2013.' He reported that seeing (person of color) people is a trigger for him. Resident #117 was verbally aggressive toward staff and refused care. On 2/7/23 at 3:54 p.m. the nursing notes documented, Nursing entered patient room and he yelled at her, stating, 'Get out of my room before I call 911.' On 2/8/23 at 9:15 a.m., the nursing notes documented, Resident refused to have VS (vital signs) taken, while yelling obscenities at and making derogatory remarks to CNA #3. On 2/8/23 at 1:44 p.m., the skilled nursing note documented, Resident intermittently agitated, anxious, verbally abusive to staff, decreased participation, depressed feelings or statements, anger issues, verbal behavior directed to others, rejection of care Resident expresses frustration with facility, staff, overwhelmed by number of different people caring for him. On 2/8/23 at 3:19 p.m., the social service note documented, Writer spoke with the resident's representative later about Resident #117's reports that staff were 'getting in his face and yelling at him' The note further documented that the resident and the resident's representative had been offered mental health services on 2/6/23 and had declined. The care plan and progress notes were reviewed from 2/3/23 to 2/8/23. There was no documentation that the care plan had been reviewed with the resident or resident's representative within 48 hours of admission. IV. Interviews CNA #3 was interviewed on 3/29/23 at 11:50 a.m. She said she remembered Resident #117 and had cared for him. She said Resident #117 was outspoken and cussed sometimes or called the staff names. She said when Resident #117 did cuss or call her names; she had no specific interventions for his behavior. She said she was not aware he had a history of being physically assaulted, his anxiety or depression. CNA #3 said she had never been told about any specific approaches, interventions or triggers for Resident #117. CNA #3 went to the nurse's desk and pulled up Resident #117's care plan on the computer. She said there was no care plan with interventions for his behavior or depression. CNA #5 was interviewed on 3/30/23 at 8:40 a.m. She said she did not know if behaviors with specific approaches were part of the resident's care plan. CNA #6 was interviewed on 3/30/23 at 8:47 a.m. She said she had behavior training in the past for residents with aggressive behavior, but she did not know how the staff would know what specific approaches to use with a resident who had behavior issues and or a history of trauma. The social service director (SSD) and social service assistant (SSA) were interviewed on 3/30/23 at 10:30 a.m. The SSD said that residents should have a care plan with specific interventions for behavior, including a history of trauma and triggers for behavior. She said she thought his trauma could be part of his agitation, but she did not know. She reviewed the care plan on her laptop and said there was no care plan related to his behavior, interventions for depression, or trauma. She said he should have had a care plan, and that the care plan would link to a kardex (abbreviated plan of care) for the CNAs to use. She said the baseline care plan is done within 48 hours of admission. She did not know if there was documentation that the baseline care plan had been reviewed with the resident or family, but she said the SSA talked to the resident's representative frequently. -The baseline care plan failed to include anxiety with depression, the resident's behavior, and possible triggers such as pain or history of trauma. It was not revised during his stay despite multiple documented entries in the electronic medical record (EMR) beginning on admission of feeling anxious, and throughout his stay, refusing care, and verbal aggression and distress. There was no evidence the baseline care plan was reviewed with the resident or the resident representative for input into choices or approaches that would be helpful for the resident within 48 hours or anytime thereafter. V. Facility follow-up On 3/31/23, after the survey exit, the facility sent a document in an email, undated, unsigned which documented, Review of 62 pages of hospital records there was no indication that Resident #117 experienced trauma in his history. There was mention that Resident #117 had a diagnosis of altered mental status with recent ETOH (alcohol) abuse and potential dementia diagnoses. Charting did also indicate potential paranoid delusions with unknown causes. Hospital documentation clearly stated no emotional abuse, physical abuse or sexual abuse had occurred. This was stated several times in the hospital documentation. There was no prior knowledge or documentation that Resident #117 had experienced trauma. He was diagnosed with depression and prescribed Venlafaxine to treat. There was no diagnoses of post traumatic stress disorder in any of the documentation. There was no indication to initiate a baseline care plan for trauma within the initial 48 hour period. The resident had exhibited behavioral disturbances and angry outbursts with staff soon after admission, so on 2/6/23 staff offered the option of mental health services to (resident name) and his family member, but these services were declined. Social service staff followed policy and procedure and conducted the initial social service assessment on 2/7/23 and during this assessment Resident #117 reported a past traumatic event. On 2/8/23 Resident #117 decided that he wanted to discharge back to the community against medical advice. -However, the baseline care plan did not include the resident's history of anxiety with depression or any of the behaviors documented in the progress notes that occurred almost daily. The admitting nurse documented on day one the residents anxiety, and feeling withdrawn at times. The resident's verbal aggression began soon after admission. The facility never developed a baseline care plan for the behavior. The staff were unaware of approaches to take with the resident. On 2/7/23, the social service assessment documented trauma related to a physical assault. Her assessment did not include any interventions or preferences from Resident #117. The trauma was not included on the baseline care plan either.

Based on record review, interviews, and observations the facility failed to develop a comprehensive care plan for two (#75 and #4) out of eight residents out of 47 sample residents for services to attain or maintain the residence highest practical physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Ensure the care plan for Resident #75 reflected activity preferences; and, -Ensure the care plan for Resident #4 reflected dental needs. Findings include: I. Facility policy and procedure: The Care Plan policy, revised November of 2022, was received by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed in pertinent part, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. The care plan is developed by the IDT which includes, but is not limited to the following professions: attending physician, registered nurse responsible for the resident, dietary supervisor/dietitian, social services staff member responsible for the resident, rehabilitation specialist physical, occupational, and or speech therapist as indicated, consultants (as appropriate), director of nursing services (as applicable), nursing assistance responsible for care, others as necessary or indicated. II. Resident #75 A. Resident status Resident #75, age 86, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included dementia, emphysema (shortness of breath), depression and anxiety. The 1/17/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. He required extensive assistance of two staff members for transfers, and extensive assistance of one staff member for dressing and mobility assistance. B. Record review The care plan with a date of 12/2/22 did not reveal a section for activity preferences for Resident #75. The MDS quarterly review dated 1/17/23 revealed an assessment had not been completed. The 1/18/23, quarterly activity review, progress note revealed Resident #75 enjoyed being in his room watching television programs that involved news, sports, or watching movies. It revealed Resident #75 would occasionally attend group activities involving music or being outside. It revealed Resident #75 would accept monthly visits from a Chaplain. It revealed Resident #75 would accept social visits from staff two or three times a week to provide updates and inquire if needs were being met. It revealed a care plan was in place that reflected interests, needs, strengths, and abilities of Resident #75. C. Staff interviews Activities director (AD) # 1 was interviewed on 3/30/23 at 11:00 a.m. She said she was unable to locate an activities care plan for Resident #75. She said that the facility transitioned to a new charting system recently. She said Resident #75 did not have a care plan for activities. Certified nurse aide (CNA) #1 was interviewed on 3/30/23 at 11:30 a.m. He said that Resident #75 enjoyed watching television and went to the dining room for lunch occasionally. CNA #1 said he was not aware of other activities the resident enjoyed. Registered nurse (RN) # 2 was interviewed on 3/30/23 at 4:00 p.m. She said Resident #75 enjoyed watching television, specifically investigation series. She said Resident #75 would go to the dining room for lunch occasionally. She said she was not aware of any other activities the resident enjoyed. CNA #8 was interviewed on 3/30/23 at 6:30 p.m. She said Resident #75 enjoyed watching television. She said she was not aware of any other activities the resident enjoyed. 20287 III. Resident #4 A. Resident status Resident #4, age 62, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO) diagnoses included dysphagia (swallowing difficulty) and hypertension. The 2/8/23 minimum data set (MDS) assessment coded the resident with a brief interview for mental status of 13 out of 15. The resident required extensive assistance with personal hygiene. The MDS dated [DATE] was coded incorrectly and documented the resident had no natural teeth. -However, the resident did have natural teeth. B. Record review The care plan with a review date 1/3/23 of did not reveal a section for dental care needs for Resident #4. The 1/20/23 dental note documented an oral evaluation and the chief complaint was pain to the both upper and lower posterior teeth. (#30 tooth) and (#2 tooth). The note documented an offer would be developed and possible extractions. C. Staff interview The MDS coordinator (MDSC) was interviewed on 3/30/23 at approximately 4:00 p.m. The MDSC said the dental care plan would be developed if the resident had an acute issue. He was not aware of the dental issues the resident was experiencing.

Based on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#57 and #87) out of 47 sample residents. Specifically, the facility failed to: -Ensure Resident #57 was provided repositioning and personal hygiene assistance in a timely and consistent manner; and, -Ensure Resident #87 was provided timely incontience care. Findings include: I. Resident #57 A. Resident status Resident #57, under age 65, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), the diagnoses included acute respiratory failure with hypoxia (low oxygen levels), depression, chronic pain, anoxic brain damage (complete lack of oxygen to the brain), dependence on supplemental oxygen, and anxiety. The 1/20/2023 minimum data set (MDS) assessment revealed the resident was in a persistent vegetative state with no discernible consciousness (coma). She was dependent on extensive assistance of two staff members with positioning in bed, transfers, dressing, eating, toilet use, and personal hygiene tasks. B. Observations A continuous observation was conducted on 3/28/23 beginning at 10:27 a.m. and concluded at 1:43 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Resident #57 was observed to be unkempt as evidenced by facial hair grown out on her chin, her nails were approximately an inch in length from the cuticle, unfiled, with beige nail polish grown out appropriately a quarter of an inch from the cuticle. No staff were observed entering room of Resident #57 during the continuous observation. At 2:30 p.m. Resident # 57 was observed to be lying in bed positioned on her back. A continuous observation was conducted on 3/29/23 beginning at 8:30 a.m. and concluded at 10:55 a.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. No staff were observed entering room of Resident #57 during the continuous observation. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/29/23 at 11:00 a.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. A continuous observation was conducted on 3/29/23 beginning at 2:35 p.m. and concluded at 3:44 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. One staff member was observed entering the room of Resident #57 for a 10 minute duration of time. Upon exit of staff member, Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/29/23 at 4:30 p.m. Resident #57 was observed to be lying in bed positioned on her back with the head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. On 3/30/23 at 2:25 p.m. Resident #57 was observed to have the lower portion of the bed adjusted to bend knees, head of the bed elevated approximately 30 degrees; hospital gown presented as a different color and pillows were observed under the left side of her lower and middle back area. Resident #57 was observed to be unkempt as evidenced by facial hair grown out on her chin, her nails were approximately an inch in length from the cuticle, unfiled, with beige nail polish grown out appropriately a quarter of an inch from the cuticle. At 5:15 p.m. Resident #57 was observed to be lying on her back, lower portion of the bed adjusted to bend knees, head of the bed elevated approximately 30 degrees. Facial hair was observed on the chin area and fingernails continued to be outgrown and unfiled. C. Record review The care plan, dated 1/12/23, revealed Resident #57 had an activity of daily living (ADL) self care performance deficit (unable to perform independently) related to acute respiratory failure with hypoxia (low oxygen levels), anoxic brain damage (complete lack of oxygen to the brain); additionally she had arthritis, anxiety, chronic pain, and depression. The care plan revealed Resident #57 required total assistance from staff for toilet use, bed mobility, bathing, personal hygiene, dressing, eating, and transfers. The care plan, dated 1/12/23, retrieved from facility electronic health record on 3/28/23 at 4:51 p.m. did not indicate repositioning as an intervention for the (ADL) self care performance deficit (unable to perform independently). The care plan, dated 1/12/23, was provided by the nursing home administrator (NHA) on 4/4/23 at 2:09 p.m. It revealed a revision date or 3/30/23 for a bed mobility intervention to include turning and repositioning Resident #57 frequently for comfort and integumentary optimization (optimal skin integrity). The nursing progress note, dated 3/27/23 revealed Resident #57 was on check, change, and reposition scheduled every two hours; another dated 3/28/23, revealed Resident #57 was on a check and change schedule. Multiple nursing progress notes for the month of March 2023 revealed Resident #57 was to be checked, changed, and repositioned every two hours for comfort and skin integrity. The point of care (POC) response history, with a 30 day look back period, was retrieved from facility electronic health record on 3/29/23 at 3:21 p.m. It revealed nail care was not provided. D. Staff interviews CNA #10 was interviewed on 3/30/23 at 11:30 a.m. She said Resident #57 was on a check and change schedule. She said it entailed repositioning and checking for bowel or bladder incontinence. She said the check and change was to occur every two to three hours. She said repositioning was documented once a shift. She said it entailed alternating the use of pillows under the left or right side of a resident back. She said the foot of the bed was adjusted for repositioning. She said she had not provided nail care or facial hair removal care for Resident #57. CNA #9 was interviewed on 3/30/23 at 11:45 a.m. She said Resident #57 was to be repositioned every two to three hours. She said this was because of the vegetative state of the resident. She said repositioning was documented once a shift. She said the staff were to alternate pillows and adjust the foot of the bed as a method for repositioning. She said she has not provided nail care or facial hair removal care for Resident #57. Registered nurse (RN) #3 was interviewed on 3/30/23 at 12:20 p.m. She said bed bound residents should be repositioned, and checked for incontinence every two to three hours or as needed. The director of nursing (DON) was interviewed on 3/30/23 at 2:40 p.m. She said residents who were bed bound or in a persistent vegetative state were on a check and change schedule. She said it entailed a resident being repositioned and checked for incontinence every two hours. The minimum data set (MDS) coordinator was interviewed on 3/30/23 at 6:00 p.m. He said residents who were bedbound or in a persistent vegetative state should be on a repositioning schedule. He said this information should be included in the care plan. 47960 II. Resident #87 A. Resident Status Resident #87, age 69 was admitted on [DATE]. According to the March 2023 CPO diagnoses included schizoaffective disorder, post-traumatic stress disorder (PTSD), and urge incontinence. The most recent MDS dated [DATE] showed the resident had no cognitive impairments with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required extensive assistance from one person with activities of daily living. The resident was coded as frequently incontinent of urine. B. Observations and interview On 3/27/23 at 10:25 a.m., the resident was observed and interviewed while she sat in her wheelchair. She was dressed for the day and smelled of urine. Resident #87 said she needed assistance to go to the bathroom. Although, when she rang her call light, it was not not answered timely, and she had been told by certified nurse aide (CNA) to urinate in her brief. At 3:00 p.m. Resident #87's room smelled strongly of urine. On 3/28/23 at 2:30 p.m. Resident #87's room smelled strongly of urine and when entering the room there was a strong odor of urine. On 3/29/23 at 4:00 p.m. Resident #87's room smelled strongly of urine. C. Record review The care plan last updated on 1/3/23 identified Resident #87 was incontinent of urine. Pertinent interventions included, offer toileting upon awakening, before meals, and after meals, in the afternoon and prior to going to bed. The resident required extensive assistance with toileting. D. Staff interview CNA #2 was interviewed on 3/27/23 at 10:50 a.m. CNA #2 said residents use the call lights when they need assistance going to the bathroom. She said sometimes she needed to remind the residents that CNAs could only come to help with toileting every two hours. She said sometimes the residents needed to wait so the CNAs could help the other residents.

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#1 and #2) of four sample residents reviewed for falls with injuries. Resident #1, who had a diagnoses of Alzheimer's disease and unspecified dementia with behavioral disturbance, and history of falling was admitted to the facility on [DATE]. The resident was a known fall risk and had sustained falls that resulted in femur bone fracture following joint replacement surgery prior to admission. On [DATE], the resident was found by a nursing staff member in the hallway, lying on the floor. Throughout the day, Resident #1 was seen crying, calling out, touching her pelvic area, complaining of pain in bilateral hip joints and pain during voiding. A purple bruising was noted to her left inner thigh up to the groin and an abrasion to right elbow. The resident was sent to a hospital on [DATE] for further evaluation. During the resident's hospital evaluation, it was discovered that the resident had sustained a displaced fracture of the bilateral superior and inferior pubic rami and nondisplaced fractures of the left anterior three ribs and right posterior lateral two ribs. The resident was transferred to the operating room and underwent an open reduction and internal fixation of her pelvis bones with a hardware placed by the surgeon. Due to the facility's failures, Resident #1 required hospitalization with surgery to repair her fractured pelvic bones. In addition, Resident #1 sustained two unwitnessed falls and one witnessed fall without injury following admission to the facility. The facility failed to timely implement appropriate approaches to prevent the resident's fourth fall with major injuries. Resident #2, who had a diagnoses of diabetes mellitus, spinal stenosis and disorders of bone density, required two staff for all transfers with a mechanical lift (Hoyer). On [DATE] two certified nurse aides (CNAs) assisted the resident with a Hoyer lift from her bed to her wheelchair. During the transfer, the mechanical lift's arm holding Resident #2 in a sling broke off from the lift's frame. Resident #2 fell to the floor with the lift's metal arm falling on her. The resident complained of severe back pain and sustained large skin tears on her left forearm. The resident was sent to a hospital for further evaluation. During the resident's hospital evaluation, it was discovered that the resident had sustained a left ischial bone fracture, left inferior pubic rami bone fracture, and left lumbar (L3) bone fracture. The facility failed to ensure Resident #2 safe transfer with a mechanical lift (Hoyer). Due to the facility's failure of a thorough lift inspection, Resident #2 sustained multiple bone fractures and was hospitalized . Findings include: I. Facility policy and procedure The Falls and Fall Risk policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:11 a.m. It read in pertinent part, The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If a systematic evaluation of resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions . If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identify or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable .The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling .If the resident continues to fall, staff will re-evaluate the situation and weather it is appropriate to continue or change current interventions. II. Resident #1 A. Resident status Resident #1, age 80, was admitted on [DATE] and readmitted on [DATE]. According to the February 2022 computerized physician orders (CPO), diagnoses included aftercare following joint replacement surgery, fracture of unspecified part of neck of right femur, Alzheimer's disease, unspecified dementia with behavioral disturbance, other specified fracture of unspecified pubis, and multiple fractures of ribs. The [DATE] minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score four out of 15. She required extensive assistance of two persons with bed mobility, transfers and toilet use, extensive assistance of one staff with personal hygiene, limited assistance of two staff with dressing, and was independent with eating. The MDS assessment further revealed the resident had a history of falling prior to admission. B. Record review Care Plan Review of Resident #1's fall care plan, initiated [DATE], revealed the resident was at risk for falls related to history of multiple falls prior to admission with right hip fracture (right hip arthroplasty), falls since admission, Alzheimer's Disease/Dementia, weakness, and psychoactive medication use. Pertinent interventions included, encourage resident to hang out in high visual areas. Dated [DATE]. Assess w/c (wheelchair) cushion for comfort. Dated [DATE]. Assessed for reacher but not able to follow instruction on use. Dated [DATE]. Review of the Fall Risk Evaluations revealed: -[DATE] score 17 (high risk) resident's admission -[DATE] score 19 (high risk) first fall -[DATE] score 18 (high risk) second fall -[DATE] score 18 (high risk) third fall -[DATE] score 20 (high risk) fourth fall Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part: -[DATE] at 2:21 p.m., Resident is confused. Level of cognitive impairment: Mild impairment (some confusion). Mood & Behavior: Mood is pleasant, no unwanted behaviors witnessed. Sleeps intermittently. Resident is coherent. Speech is clear .Resident makes self-understood. Resident understands others. Lower extremity ROM (range of motion): Impairment on one side. Gait is steady. Balance is poor. Resident is bedfast all or most of the time. -[DATE] at 12:57 a.m., Resident on follow up for recent fall, no injuries noted. Spent most of evening up at nurses station for 1:1 (one-on-one) safety care. V/S (vital signs) and neuro checks WNL's (within normal limits) for this resident. Assisted to bed X1 (times one) person, extensive cues required. Received HS (hours of sleep) meds, denies pain or discomfort. Call light within reach. Frequent rounds by staff to ensure needs are met and resident is safe. -[DATE] at 1:44 p.m., Resident being monitored for unwitnessed fall ([DATE]) without further injury. Neuro (nuerological) checks base line for resident. Denies pain r/t (related to) fall. Will continue to monitor and promoting safety and comfort. Call light in reach. Encouraging to use call light for assistance. -[DATE], Res (resident) agitated and attempting to stand up w/o (without) assist. Requiring one to one care due to behaviors/impulsiveness all shift. -[DATE], Res (resident) agitated this morning. Attempting to stand/walk w/o (without) assist. At nurses station due to requiring one to one care to ensure safety due to behaviors/impulsiveness. -[DATE], Resident this evening standing up and attempting to walk unassisted frequently. Resident agitated easily. Resident redirected frequently, with no effectiveness. Resident yells and becomes combative at times. -[DATE], Res (resident) requiring one to one supervision due to impulsive behavior, standing up w/o (without) assist. Difficult to redirect. -[DATE], Res (resident) voices some needs. Staff anticipates most needs. No c/o (complaint of) pain or discomfort. Continues on neuro checks for fall. No injury noted. Resting in recliner by nurses station at this time. -[DATE] at 4:15 p.m., This RN (registered nurse) was informed by RT (respiratory therapist) staff that resident fell forward out of her wheelchair and bumped her head; neuro check was clear and VSS (vital signs); no injuries noted at this time; family and doc (physician) notified by this RN (registered nurse); neuro protocol initiated. -[DATE] at 10:06 a.m., Heard yelling in the 30s hall. Observed (Resident) lying on her right side in the hallway mostly facing the nurse's station. RN assessed. No bleeding or bruising noted. Staff states she can walk. Assisted (Resident) to WC (wheelchair). Patient was dressed and taken to sit at the nurse's station. Staff offers comfort and distraction with music/ activities/ hand holding. She ate breakfast and took all her medications. (Name) PA (physician assistant) visited her. No new orders at this time. -[DATE] at 1:33 p.m., Patient continues to call out, cry, groan, speak to mom & dad. Grabs her peri area and cries. Says it hurts when she urinates. Also, c/o (complained of) pain in bilateral hip area. Notified (name) PA by phone. New orders for stat X-ray of abdomen and bilateral hips . Patient calms when one on one care are provided. Encouraged fluids all day. Refuses at times. Ate some lunch. -[DATE] at 2:30 p.m., Notified (name), PA by phone that patient was still crying and calling out. Requested pain medication, but he felt at that time it was not appropriate. Scheduled dose of [MEDICATION(S)] given. Told him the stat x-rays and labs were ordered but not completed at this time. Asked to send patient to the hospital. Concern was noted that if she was just behavioral then it would be more traumatic r/t related) to her confusion/ Alzheimer's than it would be beneficial. -[DATE] at 5:29 a.m., Resident is on f/u (follow up) for recent fall. Neuros and ROM (range of motion) are at baseline. Resident was in bed crying out to her mom and dad all night, was inconsolable. Became very agitated when staff attempted care. -[DATE] at 1:52 p.m., Would like to have her evaluated by ER (emergency room ) related to her inconsolable yelling out and crying post fall. We have done x-rays and labs the abd (abdomen) and pelvic x-ray are negative, blood work and UA (urinary analysis) are pending. Unable to do appropriate assessment as her responses to ROM (range of motion). (Resident) has been noted to be guarding her right hip when assessed. All other ROM assessments are undetermined as she stated all ROM cause pain. Noted purple bruising to her left inner thigh up to the groin. She has a 3x2 cm (centimeter) abrasion to right elbow. Call to (name) PA to send resident to ER for evaluation of pain. Notified (name) of pending transport to ER . This writer called gave verbal report to ER RN at (hospital). All medications secure in med cart and all personal belongings left in resident's room. The [DATE] emergency room physician note revealed, In summary this [AGE] years old with advanced dementia presents from her care facility with possibility of injury. The patient fell yesterday. In the hallway. Unwitnessed. Has been crying in pain since. There was some concern about the possibility of a hip fracture as her leg seem to be slightly shortened. Does have a history of a right hip prosthesis. No clear fracture there. But the patient does have significant injury. She has inferior and superior pubic rami fracture with anterior displacement of the free fragment. She has multiple bilateral rib fractures. She has a sacral [NAME] fracture. Trauma surgery consulted. Orthopedics consulted .The patient will be admitted to ICU (intensive care unit) on the trauma surgeon's service. C. Facility's investigation of Resident #1's falls The [DATE] post fall investigation noted, This RN was walking down the hall and heard 'oh no'. I walked in Pt's (patient's) room and saw her laying on her left side with her head near the bathroom and her feet toward the bed. Pt's (patient's) w/c (wheelchair) was beside her toward the door of the room. Pt (patient) had non-skid socks on. When asked what she was doing Pt (patient) couldn't verbalize what she was doing. PERRL (pupils equal round reactive to light), equal hand grasps. Pt (patient) moved all extremities at baseline (and with palpation all over) without grimace or c/o (complain of) pain. Neuros started, x3 (three persons) assist back in w/c (wheelchair). -The investigation did not include scheduled and consistent staff supervision, one-on-one staff with the resident, frequent incontinence care and structural activities program approaches for resident with severe cognitive impairment. The [DATE] post fall investigation noted, Resident sitting at nurses' station and found res (resident) on floor in front of w/c (wheelchair). No injuries noted. Confused conversation not able to state what she was going prior to fall. -The investigation noted a nurse called the resident's physician and asked for increase of pain medication, however there was no assessment of Resident's #1's pain level while she was seated in her wheelchair at the nurses' desk for extended periods of time, and did not include any new approaches to keep the resident occupied. There were no staff present to supervise the resident and prevent this fall. The [DATE] post fall investigation noted, Res (resident) was reaching for something on the floor and fell out of wheelchair and hit head on floor. Fall was witnessed by RT (respiratory therapist) (name). Rambling no ability to state what she was trying to do. -The approach noted in the investigation , resident remains in a highly visible area for safety, was not sufficient to prevent resident's third fall, and second fall while at the nurses' desk. The [DATE] post fall investigation noted, Heard yelling in the 30s hall. Observed (resident) lying on her right side in the hallway mostly facing the nurse's station. (Name) RN assessed. No bleeding or bruising noted. Staff states she can walk. Assisted (resident) to w/c (wheelchair) after assessment. Resident unable to give description. Further a nurse noted, This writer called to assess resident who was laying in the middle of the hallway outside of the resident room. Wheelchair was located in the room by resident's bed. Resident alert and oriented x1-self. Resident tearful during assessment, unable to communicate areas of pain. Resident able to move all extremities. No increase of outward signs of pain while moving extremities. Resident attempting to sit up during assessment. Resident unable to communicate if head was hit. Neuros initiated per protocol and intact. Four staff assist to resident wheelchair. -The investigations did not reveal immediate interventions including but not limited to timely and frequent toileting schedule, incontinence care, appropriate pain assessment for resident with severe cognitive impairment, and one on one close supervision. The resident who was admitted to the facility after a fall at home and post hip replacement surgery, agitated, impulsive, was frequently placed at the nurses' station, in her wheelchair, for close supervision which did not prevent falls. D. Interviews The nursing home administrator (NHA) was interviewed on [DATE] at 10:20 a.m. He said all falls were reviewed during the stand-up meeting in the mornings. He said unit managers brought records of fall that occurred in the past 24 hours and interventions were discussed. Registered nurse (RN) #1 was interviewed on [DATE] at 10:55 a.m. She said after the fall on [DATE], Resident #1 was frequently placed in her wheelchair next the nurses' station for staff to have close supervision of the resident due to her anxiety and poor safety awareness. She said nursing staff was conducting frequent checks on the resident, however, structural every 15 minutes checks were not implemented. She said the resident had severe cognitive deficit and did not know how to use a call light. She said the resident was frequently agitated and tried to stand up from her wheelchair often, without asking for assistance. She said Resident #1 was weight bearing as tolerated and staff could transfer her with a gait belt. RN #2 was interviewed on [DATE] at 11:14 a.m. She said Resident #1 was on the North skilled unit after her admission for rehabilitation, and then moved to the West long term care unit. She said the resident was agitated and attempted to stand up without assistance from bed and wheelchair. She said the resident was frequently placed in her wheelchair by the nursing station for staff to watch her. She said on [DATE] around 7:00 a.m. she observed the resident on the floor, on the hallway next to her room. She said a CNA was already with the resident. She said a licensed practical nurse also came to the resident and vital signs were taken. RN #2 said she tried to assess resident's pain however the resident was trying to get up. Resident #1 was crying a little bit. There were four or five staff, we used a gait belt to stand her up and assisted the resident to the wheelchair. The resident was still crying. She said the facility has no lift policy and the residents usually were lifted by a Hoyer lift after a fall, however because the resident was trying to stand up the staff decided it was the safest way to put her on the wheelchair by standing her up with a gait belt. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 8:55 a.m. She said on [DATE] at approximately 7:00 a.m. she was at her medication cart when she heard Resident #1 yelling. She said the resident was laying on the floor, on the hallway, next to her room. She said an RN came immediately and tried to assess the resident. She said the resident was crying however could not specify areas of pain. She said four staff assisted the resident up from the floor to her wheelchair using a gait belt. She said after the fall the resident was placed by the nurses' desk so the staff could keep their eyes on her. She said Resident #1 continued to cry, called her parents (deceased ) for help. She said the resident was transferred to bed and the PA was called to assess her. She said x-ray and lab works were ordered. RN #1 was interviewed on [DATE] at 9:05 a.m. She said the facility had no lift policy and nursing staff should use a mechanical lift for all residents after a fall. She said however, depends on a case, when resident is agitated, confused, and tries to stand up, staff will use a gait belt for transfer. III. Resident #2 A. Resident status Resident #2, age 86, was admitted on [DATE]. According to the [DATE] CPO diagnoses included type 2 diabetes mellitus with diabetic chronic kidney disease (stage III), long term use of insulin, long term use of anticoagulants, spinal stenosis and disorder of bone density. The [DATE] MDS assessment revealed the resident cognition was moderately impaired with a brief interview for mental status (BIMS) score 12 out of 15. She was totally dependent on two staff with transfers, required extensive assistance of two staff with bed mobility, dressing, toilet use and personal hygiene, and was independent with eating. B. Record review Care plan Review of Resident #2's comprehensive care plan, revealed the resident was at risk for falls related to history of falls due to poor balance, diabetes mellitus, muscle weakness, activities of daily living deficit, pain, diffuse osteopenia. Left ischial and left inferior pubic ramus fractures on [DATE]. Date initiated [DATE] with revision on [DATE]. Resident also had activities of daily living, self-care performance deficit and limited mobility related to chronic respiratory failure, diabetes mellitus, obesity, muscle weakness, [CONDITION(S)], left ischial and left inferior pubic ramus fractures on [DATE]. Date initiated [DATE] with revision on [DATE]. Interventions included: Transfer: (Resident) requires utilization of a Hoyer lift for and during transferring with two staff present. Date initiated [DATE] with revision on [DATE]. Review of Resident #2's electronic medical record (EMR) revealed the following progress notes documented in pertinent part: -[DATE] at 8:38 a.m., LPN documented: CNA came running up to this writer stating 'the Hoyer lift broke and (resident) is on the floor.' I ran down to (resident) room and observed (resident) on the floor with the fastening device (bracket) across her arms and chest that had broken away from the machine. There were 2 (two) CNAs in the room assisting with the transfer. (resident) was having severe back pain and 2 (two) skin tears were noted to her left forearm 4.0 cm x 3.0 cm and 4.0 cm x 2.0 cm. The other LPN on the floor ran to get an RN. (name) RN came over to assess (resident), while the RN was with (resident) I ran and called (physician) on call, I received orders to send (resident) out 911. I immediately called 911. I then notified POA (power of attorney)/daughter (name). -[DATE] at 8:40 a.m., RN documented: (name) LPN notified this nurse resident is on the floor during transfer due to Hoyer lift broke. Resident was on the floor lying on her back, assessed alert and oriented, neuro assessment baseline, ROM (range of motion) on RUE (right upper extremity), LUE (left upper extremity) and RLE (right lower extremity) baseline. Resident unable to move LLE (left lower extremity) complaining pain. Resident had 2 (two) skin tear on left forearm 4 cm x 3 cm and 4 cm x 2 cm. Resident was complaining back pain. -[DATE] at 11:00 p.m., LPN documented: res (resident) arrived from (name) hospital accompanied by EMT 2 person on stretcher. res (resident) A and O x3 (alert and oriented to time, place and person) pleasant, assessment done. skin dry multiple bruises on both arms and some bruises on right lower leg. dark spot on left lower legs. Res (resident) ate her meals 50% and fluids 120 ml. res (resident) moaning while reposition, Tylenol given with positively result. family at bedside. no c/o (complaints) noted. -[DATE] a physician documented: returned from the hospital after a pelvic injury and fracture; also has a left forearm skin tear; for the sacral fx (fracture) no surgery was needed; she had severe pain initially but today she reports her pain is much improved; she report to me that Tylenol has been effective today; has a good appetite today; no anxiety. C. Facility investigation of Resident #2's fall The [DATE] Incident investigation report revealed that during the Hoyer lift transfer the bracket broke away from the lift causing Resident #2 to fall. Witness statements included the following: -CNA #1 noted, Me and (CNA#2) were getting the resident up this morning. I put all the same color blue on the sling and we pulled her out from the bed and turned close to her w/c (wheelchair). (CNA#2) was right there. As I started opening the legs of the machine , the bracket of the machine broke and the resident fell on the floor. She was still on the machine and the machine wasn't making any unusual noises before. We called the nurse right away. -CNA #2 noted, Myself and (CNA #1) were getting resident up for the day. Resident was dressed completely in bed. Hoyer sling was in place on resident. The Hoyer sling was on the blue hooks on the sling. Resident had the correct size of Hoyer sling in use. As Hoyer was moved in slow process away from the bed the legs on the Hoyer was being opened to put Hoyer in place to place resident in w/c (wheelchair). In an instant the bracket (sic) dropped. Resident fell to the floor in an instant the bracket fell on top of her because it was attached to the sling that the resident was using. It was on top of arms and chest area. CNA (#1) left room right away to call nurse for help. Machine was in good working condition and nothing noted to be wring with it. Six other staff members reported they did not have any concerns with the Hoyer lifts used in the facility. Further the investigation documented the NHA and DON completed visual and functional assessment of lifts. The NHA contacted an outside company for an inspection of all lifts used in the facility. Hospital records On [DATE] at 1:53 p.m. a physician documented: (Resident #2), a [AGE] years old female who fell off a Hoyer lift and sustained a stable left pelvic fracture. There is a comminuted left ischial fracture with extension into the inferior pubic rami. No large hematoma .Patient was evaluated by orthopedic surgery and they did not feel there was any surgical intervention needed and patient can be weight bearing as tolerated. They felt the fracture was stable. D. Interviews The NHA was interviewed on [DATE] at 12:00 p.m. He said all mechanical lifts were inspected monthly by the maintenance director. He said he never experienced in his career as an administrator in nursing facilities any major issues with mechanical Hoyer lifts. As he demonstrated the broken lift, he explained how the bolt that should hold the lift's arm to which a sling was attached, came off the frame. He said he personally inspected all mechanical lifts in the facility right after the incident. He said he signed a contract with an outside company to inspect all mechanical lifts in the facility monthly. CNA #1 was interviewed on [DATE] at 12:55 p.m. She said on [DATE] at approximately 7:30 a.m. she and CNA #2 assisted Resident #2 with her morning routine to get her ready for breakfast. She said she brought the Hoyer lift into the resident's room. She said the sling was already under the resident. She said both CNAs hooked the sling to the lift's arm and started lifting the resident of the bed. While the resident was off the bed they tuned the lift with the resident up in the air toward the resident's wheelchair. She said when she started spreading the Hoyer lifts legs to fit under the resident's wheelchair, the arm holding the sling with resident in it broke off and resident fell to the floor approximately three feet down. She said Resident #2 started crying from pain and her left arm was bleeding because the lift's metal arm fell on her left arm and caused skin tears. She said she called the nurse on the unit and two nurses came to assess the resident. She said paramedics arrived, picked the resident off the floor and transported to a hospital. She said she has been working in the facility for over two years. She said she was always very confident with residents' transfers using a Hoyer lift. She said after she was hired the facility provided an extensive three days orientation/training to all CNAs and that included safety with transfers using all mechanical lifts in the facility. Resident #2 and her daughter were interviewed on [DATE] at 3:50 p.m. The resident said she remembered the sharp pain in her lower back after the fall. She said she did not remember what really happened and why she fell . She said she still feels the pain when she sits in her wheelchair for long periods of time. The resident's daughter said the facility was responsible for the mechanical lifts used to transfer residents. She said it was neglectful to use a malfunctioned lift to transfer her mother. The maintenance director was interviewed on [DATE] at 9:30 a.m. He said he inspected all mechanical lifts in the facility monthly. He said most of the time a battery or an activator (lifting mechanism) needed replacement. He said it was a simple task to complete. He said an arm falling off the lift's frame was a mystery never heard of and never happened before.

Based on interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure the water management plan for legionella was effective by including the maintenance director in the process for completing the water management plan and providing him documentation that a water management plan existed. Furthermore, the facility failed to ensure the monitoring of control measures were conducted such as disinfectant flushes and testing (which were identified in the water management plan) were conducted weekly or at all. Lastly the facility failed to ensure testing for legionella was completed to determine if the control parameters were sufficient in preventing legionella and ensuring an effective water management program. By the facility failing to ensure an effective water management plan and execution, Resident #1 was exposed to Legionella, contracted legionnaire's pneumonis, experienced an acute change of condition, which resulted in decreased oxygenation, intubation and ultimately, Resident #1's death. The facility failures required immediate correction to prevent serious harm to other residents residing in the building. Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy On June 30, 2021, Resident #1 experienced a change of condition exhibited by acute respiratory distress. Her oxygen saturation dropped to 68-73% on 5LPM (liters per minute) of oxygen and stayed between 76-80% on 10LPM and a non-rebreather mask. Upon being transferred to the hospital, the resident was diagnosed with Legionnaires pneumonis and intubated because her respiratory status continued to deteriorate. Resident #1 passed away at the hospital. The facility failed to ensure the water management plan for Legionella was effective by conducting monitoring of the control measures, such as disinfectant flushes and testing to ensure a Legionella outbreak did not occur at the facility. By failing to ensure an effective water management plan was in place and implemented, Resident #1 was exposed to Legionella, contracted Legionnaires pneumonis, experienced an acute change of condition and ultimately Resident #1's death. B. Imposition of immediate jeopardy On 7/28/21 at 1:00 p.m. the interim nursing home administrator (INHA), interim director of nursing (IDON) and infection preventionist (IP) were notified of the immediate jeopardy situation created by the facility's failure to prevent legionella pneumonis for Resident #1. C. Facility plan to remove immediate jeopardy On 7/28/21 at 6:49 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: 1. Corrective action -On 7/7/21, the facility was notified of a legionella diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] -On 7/8/21, the facility reported the case of legionella to the state health department. -On 7/23/21, the director of nursing (DON) educated all staff present and staff prior to beginning their shift, on legionella in water and no use of sinks for handwashing or drinking. No showers scheduled. Sinks located in the main dining room, kitchen and laundry are acceptable to use as on a dedicated and negative hot water heater. The DON/designee taped off all sinks in resident rooms and showers to provide visual markings. Stop signs were provided for residents that did not understand the purpose of the tape. The nursing home administrator (NHA) contacted a water consultant and set up a consultation for 7/26/21. -On 7/24/21, the maintenance director (MD) completed the recommended action by the local health department; a superheating of the water system to include all sinks, showers and hot water heaters. The shower heads, tubing and vac breaker were replaced. -On 7/26/21, a meeting was held with the state and local health department to discuss the risks of utilizing the water system prior to legionella re-testing. The facility utilized low risk sinks. The sinks and showers were marked off with tape. Portable hand washing stations were delivered for handwashing. -On 7/27/21 a water/swab was collected and submitted to the state health department lab. Results could take 10-14 days. -On 7/28/21, the staff development coordinator (SDC), completed legionella training to include the current water management plan with the maintenance director and interim NHA. -By 8/6/21, the water consultant (WC) will complete a water risk assessment, review and update the current water management plan. 2. Identification of others -Beginning on 7/15/21 and for the next 90 days, residents with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . If the UAT is positive, the sputum test will be collected for culture and confirmation of species identification. -On 7/28/21, the IP reviewed and completed a 90 day review of all respiratory infections. All residents will be monitored for signs and symptoms of respiratory illness utilizing the current COVID-19 screening on the treatment administration records (TARS). 3. Systemic changes -On 7/29/21, the SDC/designee will educate all staff on the signs and symptoms associated with pneumonia and legionnaires, reporting biofilm, scales, sediment, water pressure changes and water stagnation to water sources. -By 8/6/21, the WC, will complete a water risk assessment and review/update the current water management plan. 4. Monitoring -Upon water use resumption, chlorine levels and water temperatures will be obtained two times per week on each unit for 30 days, then weekly for 60 days. Further testing recommendations will be determined during the water risk assessment and review/update of the water management plan with the water consultant. The NHA will review the results of the water management plan and report to the quality assurance performance improvement (QAPI) committee. -Upon water use resumption, vacant room sinks will be flushed weekly for 90 days. Further flushing recommendations will be determined during the water risk assessment review with the water consultant. Updates to the plan will be made based on those recommendations. D. Removal of the immediate jeopardy The above plan was accepted on 7/28/21 at 6:49 p.m., and the immediate jeopardy was removed. However, record review and interviews revealed deficit practice remained at a G level, actual harm that is isolated. II. Professional reference According to the Centers for Disease Control (CDC) website, Legionella (Legionnaires' Disease and Pontiac fever) https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html (Retrieved 8/3/21), Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires' disease. Some water systems in buildings have a higher risk for Legionella growth and spread that others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Your building may need a water management program to reduce the risk for Legionnaires' disease associated with your building water system and devices. This water management program should identify areas or devices in your building where Legionella might grow or spread to people so that you can reduce that risk. Your program team should establish procedures to confirm, both initially and on an ongoing basis that the water management program is being implemented as designed and effectively controls the hazardous conditions throughout the building water systems. This step is called validation. Environmental testing for Legionella is useful to validate the effectiveness of control measures. The program team should determine if environmental testing for Legionella should be performed and, if so, how test results will be used to validate the program. III. Facility policy and procedures The Legionella Water Management Program policy and procedure, revised July 2017, was provided by the nursing home administrator (NHA) on 7/26/21 at 12:42 p.m. It revealed, in pertinent part, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. The water management team will consist of at least the following personnel: the infection preventionist, administrator, medical director, director of maintenance and the director of environmental services. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires disease. The water management program used by our facility is based on the Centers for Disease Control and Prevention (CDC) for developing a Legionella water management program. The water management program includes the following elements: -An interdisciplinary water management team; -A detailed description and diagram of the water system in the facility; -The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria; -The identification of situations that can lead to Legionella growth; -Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature, disinfectants); -The control limits or parameters that are acceptable and that are monitored; -A diagram of where control measures are applied; -A system to monitor control limits and the effectiveness of control measures; -A plan for when control limits are not met and/or control measures are not effective; and -Documentation of the program. IV. Resident #1 who contracted legionella pneumonis A. Resident #1 status Resident #1, age 88, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 4/20/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of one out of 15. She required extensive assistance of two people with bed mobility, dressing and toileting and extensive assistance of one person with transfers and personal hygiene. It indicated the resident used supplemental oxygen. B. Record review revealed the resident contracted legionella pneumonis while she resided at the facility The oxygen therapy care plan, initiated on 1/14/21, documented the resident required oxygen therapy related to ineffective gas exchange associated with COVID-19, pneumonia, acute and chronic respiratory failure with [CONDITION(S)] (deficiency in the amount of oxygen reaching the tissues) and obesity. 1. Resident #1 change in condition The 6/30/21 nursing progress note, documented at 11:30 a.m., indicated the nurse was called to Resident #1's room due to a low oxygen level. It indicated the resident had increased work of breathing with shallow respirations and crackles throughout the resident's lungs but increased on the left side. The resident's oxygen saturation was 68-73% on five liters per minute (LPM) of oxygen. The oxygen was increased to 10LPM and then Resident #1 was placed on a non-rebreather mask. The resident's oxygen saturation stayed between 76-80%. The resident was awake and answered yes and no questions. The physician was notified and an order was given for the resident to be sent out to the hospital via 911 emergency services. 2. Hospital documentation The 6/30/21 emergency room (ER) admission notes revealed the resident presented in the ER at 11:22 a.m. with respiratory distress. In the ambulance on the way to the hospital, Resident #1 was placed on an additional 6LPM of oxygen via nasal cannula, but her oxygen saturation remained in the 80% range. The resident also became hypotensive (abnormally low blood pressure) with a systolic (pressure in the arteries when the heart beats) of 86 and tachycardia (rapid irregular heart beat) to the 120's. The pulmonary assessment showed mild tachypnea (excessive rapid breathing) without the use of accessory muscles (muscles used for breathing when there is an abnormal or labored breathing pattern) and lung fields were decreased at the basis with associated bibasilar rates (bubbling or crackling sound originating from the base of the lungs). Resident #1 was evaluated again at 1:40 p.m. Her oxygen saturation was in the 70's. The ER physician contacted the resident's power of attorney, who approved the resident to be intubated (intubation is a medical procedure involving the insertion of a tube down the throat and into the windpipe to make it easier to get air in and out of the lungs). The resident was intubated on 6/30/21 at 3:44 p.m. The critical care physician documented, this was a very complex patient who presented with respiratory failure and hypoxemia. She had findings suggestive of aspiration pneumonitis on her work-up. She was noted as persistently hypoxemic. She initially responded well to the [CONDITION(S)] (bi-level positive airway pressure) and intravenous fluids, but ultimately, her pulse oxygen began to decline into the 70's. Despite multiple attempts at repositioning and adjusting the [CONDITION(S)] machine, we were not able to adequately ventilate and oxygenate this patient. Resident #1 was transferred by life flight to another hospital to the ICU (intensive care unit). Prior to being transferred to another hospital, Resident #1 was treated with empiric antibiotic therapy for a presumed healthcare associated infection. The 6/30/21 chest x-ray revealed left retrocardiac airspace opacity which may reflect atelectasis, pneumonia or aspiration and a developing small left pleural effusion. The 7/1/21 infectious disease consult notes documented Resident #1 was seen due to hypoxemic respiratory failure and shock. The resident was intubated and sedated. The urine legionella [MEDICATION(S)] test returned with a positive result. Resident #1 was diagnosed and treated for [MEDICAL RECORD OR PHYSICIAN ORDER] C. Failure in the facility response to prevent legionella 1. Water management plan The Water Management Plan for Legionella Control, undated, was provided by the INHA on 7/26/21 at 12:42 p.m. The water management plan area to document the revision date, comments and initial was left blank. The hazard identification and risk assessment table for legionella included the following control measures: -For incoming water: a medium risk level for legionella due to the supply of water with a low chlorine residual. The possible control measure: to install onsite chlorination to achieve 0.5 MG (milligram)/L (liter) at all high risk outlets. -For the hot water system: a medium risk for a water temperature too low (to inhibit the growth of Legionella and other opportunistic pathogens). The possible control measure: to measure the temperature daily and adjust if too low. -For warm water systems: a high risk due to the distance from TMV (thermostatic mixing valve - blends hot water with cold water) outlet greater than six meters leading to Legionella detections in high risk locations. The possible control measure: move the TMV closer to the outlet or install a point of use filter on the outlet. -For pipework: a high risk due to low flow in several areas (allows adherence and proliferation of Legionella and other opportunistic pathogens). The possible control measure: weekly flushing of water in areas of low use. The operation monitoring of the control measures included: -Incoming water: weekly chlorine residual testing at the point of entry of the incoming water into the facility to be recorded on the chlorine residual record sheet. -Hot water: three times per week temperature monitoring in the hot water outlet in the kitchen, sinks and kitchenette to be recorded on the daily temperature kitchen log. -Warm water: two times per week temperature monitoring in the outlet furthest from the water heater and second floor resident rooms. -Observations of the facility showed the facility did not have a second floor. Upon review of the operation monitoring the following changes were hand-written on the plan: -Incoming water: hand written documented the monitoring started the week of 7/19/21; -Hot water: hand written crossed out three times per week and wrote in weekly; and -Warm water: handwritten crossed out twice per week and wrote in weekly. D. Health department communication for the results of confirmed Legionella bacteria On 7/23/21, the local health department provided the following to the facility regarding the confirmed case of Legionnaires disease: The (state health department) received a routine disease reporting notification about a confirmed case of Legionnaires' disease in a resident at your facility. After learning from staff at the facility that the resident had spent the entirety of her exposure period (June 16-June 28, 2021) at the (facility), this was deemed presumptive healthcare-associated case of Legionnaires' disease and prompted an on-site environmental investigation. On July 12, 2021, staff from the state and local health department visited (the facility) to perform an environmental assessment, review our water management plan, and take environmental water samples from around the facility for Legionella testing. Ten water samples were collected from your facility; seven bulk water samples and three swabs. Legionella culture results revealed five of the water samples from your facility were positive for live Legionella bacteria. Positive sample results included all three samples taken from the faucet in the (resident with confirmed case of Legionnaires) room, the bulk water sample from the communal shower, and the bulk water sample from hot water heater # . The local health department made the following recommendations: 1. Water restrictions and control measures: As per the CDC guidelines, the local health department recommends that the entire facility undergo water restrictions immediately to prevent further patient exposure to aerosolized water, These restrictions included no shower use by patients, no running faucets in patient rooms or anywhere patients have access, bottled water to be used for all drinking water, and no use of ice by patients. In order for patients and staff to perform frequent hand hygiene while sink faucets are not available, ensure that alcohol-based hand get is available in all bathrooms, patient rooms, as well as kitchen and dining room areas. Encourage all patients and staff to utilize this alternative method for hand hygiene during the water restriction period. These instructions will remain in place until remediation of your water system is complete. We further recommend halting new admission until the water system is remediated. The above water restrictions can be lifted after mitigation has been performed and the water system has been flushed. 2. Hire a Legionella consultant to perform an environmental assessment to determine the appropriate remediation for your potable water system: Hire a Legionella consultant to perform an in-depth environmental assessment to determine the appropriate remediation for your potable water system (either hyperchlorination or superheating). The environmental assessment serves to identify possible exposure sources that may have led to Legionella infection. This bacterium grows exclusively in damp, moist areas, and therefore the investigation should focus on environmental sources in which the patient was exposed to water, humid air, and liquids that could be aerosolized. 3. Remediation of potable water system and resident notification: Work with the Legionella consultant to determine which remediation method is appropriate for your facility. Perform remediation and flushing to eliminate Legionella from the water system using protocols derived from ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers)12-2000 and ASHRAE 12-2020. We recommend notifying residents of the positive water samples and remediation plans. Restrict access to water fixtures while remediation is performed. 4. Follow-up Testing: To ensure the effectiveness of remediation, collect water samples for Legionella testing 48 hours after the water system has been restored to normal operating conditions. 5. Retrospective, Active, and Prospective Surveillance: Recommendations for Retrospective Surveillance: Perform a review of medical records looking for all positive [CONDITION(S)] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Recommendations for Active and Prospective Surveillance: Perform active and prospective surveillance for all cases of healthcare-associated pneumonia for at least three months. hospitalized patients diagnosed with healthcare-associated pneumonia, should be tested for Legionella using a sputum culture and urine [MEDICATION(S)] test. The purpose of this surveillance is to identify any additional cases of healthcare-associated [CONDITION(S)]. In order to perform this surveillance, clinicians ordering diagnostic testing will be notified of this recommendation. Report any cases of healthcare-associated pneumonia and/or patients who test positive for Legionella to the state health department as soon as possible. V. Staff interviews The INHA, MD, infection preventionist (IP) and interim director of nursing (IDON) were interviewed on 7/27/21 at 2:01 p.m. The INHA said Resident #1 had a change of condition on 6/30/21 and was sent to the hospital because her oxygen saturation had decreased on high flow oxygen. She said upon assessment by the nurse, the physician ordered the resident be transferred to the hospital. She said Resident #1 was intubated and moved to the intensive care unit. She said the resident had been diagnosed with legionnaires pneumonis. She said the facility was notified by the hospital of the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the local and state health department had come to the facility and conducted testing. She said Legionella had been found in the faucet of Resident #1's room and in bulk water samples in the shower room and another location. She said the local and state health department had placed the facility on a water ban while the Legionella was being mitigated. She said Resident #1 did not recover from the legionnaires pneumonis and passed away at the hospital. The water consultant (WC) was interviewed on 7/27/21 at 3:52 p.m. He said he had been hired by the facility based on the directive from the local and state health departments. He said he had assisted the facility with performing a 30 minute high temperature water flush of the system this past weekend. He said he had performed testing of outlets and bulk water for further Legionella testing following the high temperature water flush. He said all the hot water heaters were drained at the facility and refilled with the appropriate temperature. He said it was industry standard to perform weekly flushes of the water system, including the flushing of all outlets (for example faucets, showers, eye wash stations). He said the facility had been performing monthly water flushes of the hot water heater, however those flushes were not for Legionella control measures, but maintenance of the hot water heater. He said the facility had a chlorine based system. He said all chlorine flushes should be completed weekly, not monthly, at a minimum. He said ideally, the chlorine flushes should occur twice per week to ensure maximum effect. He said the facility had not been performing any water flushes of stagnant outlets. He said stagnant outlets were considered faucets of rooms that were unoccupied, eye wash stations, etc. He said he had reviewed the facilitiy's water management plan for Legionella. He said it was a standard form that met the requirement for having a plan, however did not actually have effective control measures to prevent the development and spread of Legionella. He said part of the water management plan did not apply to the facility layout; for example, the second floor resident rooms mentioned in the plan did not apply to the facility because the facility did not have a second floor. He said, upon his review of the water management plan, the facility was unable to provide documentation of water flushes of outlets, chlorine testing and Legionella testing had been performed at any time. He said the CDC required testing for Legionella to ensure the facility had an effective water management program. He said an effective water management plan would prevent Legionella. He said the facility did not ensure their water management plan was effective to prevent Legionella, based on the outcome of the testing, which showed a concentrated amount of Legionella not only found in the infected resident's room faucet, but throughout the facility in the bulk water tests. The INHA and the MD were interviewed on 7/28/21 at 11:40 a.m. The MD said he performed boiler flushes monthly. He said he would go to the boiler, raise the pressure release valve, hook up the hose to the bottom and run it outside, open up the boiler and keep the water flushing through. He said that was everything he did in regards to monthly flushes. He said the purpose of the boiler flush was to remove any sediment and for maintenance. He said he did not perform any other flushes to the water system throughout the facility. He said the chlorine flushes and PH testing were not being completed prior to 7/19/21. He said the chlorine flushes and hand written changes on the water management plan were added the week of 7/19/21. He said the monitoring had always been on the water management plan but had not been completed as indicated on the plan. He said he did not have any knowledge of the water management plan prior to Resident #1 contracting Legionnaires. He said the previous NHA did not include him in the development of the plan or even provide him a copy. He confirmed portions of the plan, such as the second floor resident rooms, did not apply to the facility because the facility did not have a second floor. He said prior to a couple of weeks ago, he had no involvement in setting up the water management plan or executing the control measure monitoring. He said he had no knowledge he was supposed to complete water flushes other than the water boiler for maintenance. The INHA said she was unable to find any documentation to show the facility had tested the water management plan to ensure it was effective. The MD and INHA said the facility, to their knowledge, had never tested for Legionella to ensure the water management plan was effective.

Based on observation, record review and interview, the facility failed to ensure the highest practicable quality of care for two (#4 and #10) of three out of 10 sample residents. The facility failed to prevent pressure injuries Resident #4 acquired while in their care. The resident's risks for developing pressure ulcers/pressure injuries (PU/PIs), were identified at the time of admission. However, the prevention measures specific to her needs were implemented 4 months after the resident was admitted and had acquired the pressure injuries to three places of her body. The resident required additional clinic appointments for care and treatments of the wounds. Three pressure injuries with the worst injury identified at a stage three by an outside provider. The facility failed to prevent development and worsening of in-house acquired pressure ulcers which resulted in Resident #10 experiencing an increase in pain and ensure the resident had a specific care plan for communication. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (NPUAP) Prevention and treatment of [REDACTED].cvph.org/data/files/NPIAP% 9.pdf (retrieved on 8/12/2020). It read in pertinent, -Once individuals are confirmed as being at risk or pressure injury development, a prevention program that aims to minimize the impact of modifiable risk factors identified as increasing the individual's pressure injury risk should be developed. These risk factors should be monitored regularly. In addition to a comprehensive skin assessment, a brief skin assessment of the pressure points should be undertaken during repositioning. Maintaining healthy skin requires comprehensive assessment and care planning. -Excess moisture on the skin surface (e.g. due to increased perspiration or incontinence) also increases skin vulnerability to damage related to skin maceration, pressure, and shear forces. Maintaining skin integrity is essential in the prevention of pressure injuries. -Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues, and ultimately, in tissue damage. Repositioning involves a change in position of the lying or seated individual at regular intervals, with the purpose of relieving or redistributing pressure and enhancing comfort. Mobilization involves assisting or encouraging a person to move or shift into a new position. Individuals who cannot reposition themselves will require assistance in this activity. -No support surface provides complete pressure relief. Pressure is always applied to some area of the skin. Turning and repositioning for pressure redistribution must therefore occur regularly. -Pressure and shear forces are important considerations in the development of pressure injuries in seated individuals. Limit time spent sitting out of bed for individuals at high risk of pressure injuries. II. Facility pressure ulcer protocol The Pressure Ulcers/Skin Breakdown protocol, last revised April 2013, was provided by the nursing home administrator (NHA) via email on 8/6/2020. It read in pertinent part, For assessment and recognition, staff and the attending physician will assess and document a resident's significant risk factors for developing pressure sores. The physician and staff will examine the skin of a new admission for ulcerations or indication of a Stage I pressure area that has not yet ulcerated at the surface. -For cause identification, the physician will help identify factors contributing or predisposing residents to skin breakdown and will help clarify relevant medical issues. -For treatment and management, the physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressing and application of topical agents. -For monitoring, the physician will evaluate and document the progress of wound healing and help staff modify the care plan as appropriate. III. Facility pressure ulcer risk assessment The Pressure Ulcer Risk Assessment procedure, last revised October 2010, was provided by the NHA via email on 8/6/2020. It read in pertinent part, A pressure risk assessment will be completed upon admission, with each additional assessment; quarterly, annually and with significant changes. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Staff will maintain a skin alert, performing routine skin inspections daily or every other day as needed. Nurses are to be notified to inspect the skin if skin changes are identified. Nurses will conduct skin assessments at least weekly to identify changes. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. -Documentation in the resident's record should include the type of assessment, date and time and type of skin care provided. Documentation should also include any problems, complaints, or refusal made by the resident. Observations of anything unusual should be documented. IV. Facility prevention of pressure ulcers The Prevention of pressure ulcers procedure, last revised October 2010, was provided by the NHA via email on 8/6/2020. It read in pertinent part, Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Once a pressure ulcer develops, it can be extremely difficult to heal. Pressure ulcers are a serious skin condition for the resident. The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician and family and addressed. -For a person in bed: change positions at least every two hours or more frequently if needed and determine if a special mattress is needed. -For a person in a chair: change positions at least every hour. Use foam, gel or air cushion as indicated to relieve pressure. -Refer residents to a rehabilitation program, or a restorative nursing program as indicated. Encourage the resident to participate in active and passive range of motion exercises to improve circulation. V. Resident #4 A. Resident status Resident #4, age 87, was admitted on [DATE]. According to the computerized physician orders (CPO), the [DIAGNOSES REDACTED]. The 6/9/2020 quarterly minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. Her mobility devices were a walker and wheelchair. She required extensive assistance with one person physical assistance with bed mobility, transfers, locomotion on the unit, dressing and toilet use. The resident had one moisture associated skin damaged area and one open lesion. The preventative measures included a pressure reducing cushion for the wheelchair and mattress for the bed, barrier cream and dressings applied to the wound. The resident received oxygen therapy, antidepressant, diuretic and opioid medications since admission. She had an indwelling urinary catheter and continent of bowel. The previous admission MDS, dated [DATE] assessment revealed the resident had a risk for developing pressure sores/injuries. The resident did not have wounds documented under pressure ulcers or injuries and no other wounds or skin problems were documented as zero. B. Resident observations and interviews On 8/5/2020 at 11:00 a.m. Resident #4 was sitting in her recliner in her room and began to fall toward her right side. She said she needed a pillow on that right side under her arm to hold her up from falling to the right because her back surgeries make it difficult for her to move and hold herself up. She said she preferred her wound treatments to be done at the wound clinic because she trusted her care with that wound team. On 8/6/2020 at 9:00 a.m. Resident #4 sat up in bed and faced forward with her breakfast meal on her bedside table in front of her. She started to lean towards her right side. She said, I need something like a pillow to hold me up on the right side. It feels awful like this. CNA came in to assist the resident and put a pillow under her right arm to the right side of her body. She said, Now that feels better, I can actually eat. On 8/6/2020 at 1:30 p.m. Resident #4 was assisted with one staff member and stood up from her recliner to have the wound on her left buttocks dressed. RN #1 took off the old dressing from the wound. It had a red base with soggy pale skin around the wound area. RN #1 cleansed and applied the gauze dressing to the wound. C. Record review The care plan, initiated 3/5/2020 and revised on 3/5/2020, revealed the resident had diabetes mellitus with neuropathic pain. Pertinent interventions included checking all body parts for breaks in skin and treating promptly as ordered by the doctor; Do not use over the counter remedies for corns and calluses, refer to podiatrist to treat; Inspect feet daily for open areas, sores, pressure areas, blisters, [MEDICAL CONDITION] or redness; Refer to podiatrist/foot care nurse to monitor/document foot care needs and to cut long nails. The care plan, initiated on 7/13/2020 and revised on 7/22/2020, revealed the resident was at risk for impaired skin integrity related to chronic [MEDICAL CONDITION], diabetes mellitus, [MEDICAL CONDITION], venous ulcers to the right lower extremities, wounds to the right buttocks with sheering that was intermittent and a pressure area to the left heel that is recurrent with dry cracked skin. Interventions included: -effective date 7/13/2020: Educate resident/representative about proper skin care to prevent skin breakdown; encourage resident to frequently shift weight; Evaluate skin; Monitor for moisture, apply barrier product as needed; Provide skin care per facility guidelines and as needed; Utilize compression suggestions per order. -effective date 7/22/2020: Alternating air mattress for pressure reduction on setting to two. The August 2020 CPOs contained the following pertinent orders: -order start date 3/13/2020: apply bunny boot to the left heel to prevent recurring pressure ulcers when in bed; -order start date 6/23/2020: apply protectant cream to both feet two times a day; -order start date 6/30/2020: weekly skin audits to be done once every Tuesday; -order start date 7/3/2020: inspect gluteal region dressings for intactness, if missing please replace the dressing using medicated ointment per instructions; -order start date 7/8/2020: alternating air mattress set on two and alternating for pressure reduction; -order start date 7/10/2020: to the left calcaneus(heel) to cover with bordered foam and assist the resident to apply multipurpose boot; -order start date 7/22/2020: per advanced wound care, the treatment for [REDACTED]. Also, apply a small border foam dressing to the left heel every other day. -order start date 7/27/2020: to treat the right gluteal wound with barrier cream application to periwound (the skin around the wound), apply [MEDICATION NAME] to wound bed with alginate, cover with bordered foam. -order start date 7/28/2020: please have the resident wear multi-podus boots only at night for skin integrity. -No physician order was found regarding a wheelchair cushion and no physician order was found regarding pressure reducing interventions for the resident while in the recliner, where she spends most of her time, see observation and interviews above. The 4/10/2020 nurse progress note read there was no opening at site, is on the right buttock, approximately the size of a dime. Barrier cream applied and order entered to the site to have cream applied two times a day. The 4/27/2020 nurse progress note read that the resident had an open area to her right buttock. However, no physician orders and/or documentation was found regarding the interventions put in place to prevent the right buttocks wound from opening 17 days after the facility identified the wound as a red area, see note above. The 6/8/2020 nurse progress note read that the weekly skin check was completed with open area to the right ankle and barrier cream was applied to the reddened area of the buttocks. The 6/18/2020 Braden Scale for Predicting Pressure Sore Risk form revealed that the resident's score was 17 out of 23 and that the resident was at a low risk for developing pressure sores, however she had recurring PU/PIs. The risks identified included skin was exposed to moisture occasionally, activity restriction because her ability to walk was severely limited, her ability to control body position was slightly limited and a potential problem for friction and shear. The 6/21/2020 nurse progress note read that an approximate nickel size blister was identified on her upper buttock area/iliac crest area. The 7/2/2020 nurse progress note revealed that the resident had refused dressing changes and treatments as recommended by the wound care clinic. The 7/2/2020 wound progress note revealed the resident had a stage 3 pressure ulcer on the right buttock/ischium with new wound care orders to include frequent repositioning. Right lateral malleolus with chronic venous ulcer. The left calulenous wound with orders to apply protective dressing and to apply podus boot on the left foot. The 7/3/2020 nurse progress note read the resident did not want the facility wound team to treat the wounds on her buttock and trochanter however allowed the team to assess the wounds. However, the resident did agree to let the facility wound team treat the wound as long as they followed the outside wound clinic physician orders. The 7/7/2020 physician wound orders read, Please turn patient every two hours to ensure offloading of bilateral heels and ischium. The 7/20/2020 physician wound orders read, Off load pressure on bottom, she (resident #4) needs help doing so. The 7/29/2020 Skin and Wound Evaluation form read that the resident had three in-house acquired wounds; one wound was related to moisture associated skin damage to her right buttock/ischium with 50% granulation tissue and 50% slough in the wound bed; one fluid filled blister to the right iliac crest; and one recurring deep tissue pressure injury to the left heel. C. Staff interviews Certified nursing assistant (CNA) #6 was interviewed on 8/5/2020 at 2:40 p.m. She said she received the shift report that included the residents who had been changed or repositioned. She waited for the residents to use their call to ask for assistance and as a way to check on them. She said Resident #4 is not repositioned unless she used her call light that was every three to four hours during the day. CNA #5 was interviewed on 8/6/2020 at 3:20 p.m. She stated that they do not have a specific routine to monitor or reposition residents. The resident was not repositioned unless they used the call light. She said she asked the CNA who was always on the floor, and knew how to care for a resident after she answered their call light. The wound ostomy certified nurse (WOCN) was interviewed on 8/6/2020 at 10:30 a.m. She said the risk assessment and weekly skin monitoring began when residents were admitted . Prevention measures for skin breakdown included a different mattress if the resident needed skin care or wound care as ordered at admission. The resident preferred to sit in her recliner for activities she loved to do such as knitted and talked on the phone. Staff helped with repositioning when she used the call light. Other skin breakdown prevention was implemented after staff identified pressure ulcers. Resident #4 trusted the wound clinic for directions and education rather than the facility staff. She said she was in contact with the wound clinic because the resident listened to the outside wound doctors instructions better. RN #1 was interviewed on 8/6/2020 at 10:50 a.m. She said the CNAs followed basic CNA tasks. They checked on the residents about every 2 hours to reposition them and provide care as needed. Residents who made their needs known, used the call light to be repositioned or other assistance needed. The unit manager (UM) #1 was interviewed on 8/6/2020 at 11:20 a.m. She stated the medication administration and treatment administration records had information about when residents needed to be repositioned. The nurse conducted a weekly skin check to monitor for skin problems. Resident #4 preferred to sit in her recliner most of the day there. She would be called She preferred her wound care treatments to be done by the wound clinic where she was an established patient. Even though this resident could make her needs known, no staff members indicated that encouragement was given to reposition or offload her weight. Staff waited until this resident used her call light which could be three to four hours per on staff interview above. This would not be in alignment with Resident #4 care plan (encourage resident to frequently shift weight). VI. Resident #10 A. Resident status Resident #10, under the age of 50, was admitted on [DATE] and readmitted on [DATE]. According to the August 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 6/17/2020 minimum data set (MDS) assessment revealed the resident had no short and long-term memory problems. The resident was independent with cognitive skills for daily decision making. She had no difficulties to hear in normal conversation. She was able to make self understood and able to understand others. -The MDS failed to identify communication needs such as using the white board due to being hard of hearing. She was also coded to require extensive two-person assistance for bed mobility and total dependence for dressing and eating. She was at risk for developing pressure ulcers/injuries and had one unhealed pressure ulcer/injury of Stage 2 and moisture associated skin damage. She received pressure injury care, pressure injury treatment and had pressure injury devices to the bed. She did not reject evaluation or care that was necessary to achieve her goals for health and well-being. She had occasional pain, which did not limit her day-to-day activities. She rated her pain over the prior five days as three out of 10. (This would not be accurate coding according to interviews with resident and staff members, she grimaced and cried when repositioned). -She did not receive respiratory, psychological, recreational, speech, occupational, or physical therapy. She did not receive restorative nursing services. B. Failed to prevent development and worsening of in-house acquired pressure ulcers to right elbow 1. Observation and interviews On 8/5/2020 at 10:37 a.m., RN #2 provided wound care for Resident #10's right ear and right elbow. The resident was in her bed, lying flat and rested slightly on her right side. There was an air mattress on the bed and the head of the bed was not raised. A wedge pillow was on top of furniture against the wall. The resident had a [MEDICAL CONDITION] midline on her neck with oxygen attached. A CNA held the resident's head and right arm while the nurse removed the dressings, cleansed the sites and applied new dressings. RN #2 said the resident preferred to lie in one position and sometimes the drainage from the [MEDICAL CONDITION] site ran onto the resident's ear and caused the ear to stay moist. RN #2 said staff attempted to change the resident's position from right side lying and use foam wedges but she resisted. She said the resident complained of pain, especially with movement, such as position changes. She said the resident had orders for [MEDICATION NAME] three times a day and liquid [MEDICATION NAME] every 12 hours as needed for pain. Resident #10 was interviewed on 8/6/2020 at 1:55 p.m. Using a dry erase marker and a white board, 'yes' or 'no' questions were asked. She indicated with head nods that changing position caused pain to her right arm and foot. She confirmed she did not like to change positions or have the head of her bed elevated because of pain. 2. Record review On 3/18/2020 she had an actual skin impairment/pressure ulcer related to her preference of keeping her head positioned to her right side and disregarding staff encouragement to change positioning. The skin impairment/pressure ulcer care plan initiated 6/5/19 read that the resident was at risk for skin impairment/pressure ulcer related to her need for staff assistance with bed mobility secondary to the disease process. Interventions included: -effective 10/29/19, the resident was often resistant to repositioning but please continue to offer and educate on adjustments in position for wound prevention. -effective 2/25/2020, use an alternating air mattress. -effective 3/18/2020, encourage use of a repositioning wedge to offload the right ear. The 6/19/2019 admission Braden Scale for Predicting Pressure Sore Risk form scored her risk at 11.0, high risk, and had potential for friction and shearing. The 6/17/2020 annual Braden Scale for Predicting Pressure Sore Risk form scored her risk at 9.0, very high risk, and had problems of friction and shearing. The 7/1/2020 Skin and Wound Evaluation read that the resident had an in-house acquired Stage 2 pressure ulcer to her right elbow. The Stage 2 pressure ulcer involved partial-thickness skin loss and exposed dermis. On 7/15/2020 she had an actual skin impairment/pressure ulcer related to a stage 2 pressure ulcer/injury to her right elbow. The 7/28/2020 provider note read that the right elbow had not healed with a moderate amount of sero-sanguineous drainage. The care plan failed to identify pain relief as an intervention to treating the residents refusals to be repositioned. Resident stated she did not like to change positions or have the head of her bed elevated because of pain. (see resident interview above) Furthermore the pain care plan was not resident centered (see Pain section care plan below). The August 2020 CPOs contained the following pertinent orders: -order start date 2/24/2020: use a wedge foam to reposition as tolerated and alternate sides frequently as tolerated. -order start date 7/21/2020: use an alternating air mattress. The 8/3/2020 provider note read that the resident had ongoing resistance to repositioning including for wound care to her right elbow. The 8/4/2020 Skin and Wound Evaluation read that the pressure ulcer to her right elbow had worsened to a stage 3 pressure ulcer, stage 3 pressure ulcers involve full thickness skin loss. The resident had pain when the elbow was lifted from the bed. 3. Staff interviews CNA #4 was interviewed on 8/6/2020 at 2:00 p.m. She said Resident #10 had wounds on her right elbow and they changed her position in bed when she let them. The CNA said because she cries from pain, and she preferred to lay on her right side, sometimes they would let her stay in the same position. LPN #3 was interviewed on 8/6/2020 at 2:02 p.m. She said the resident received daily wound care and dressing changes to her right elbow. Staff were supposed to change her position but she refused often and cried in pain. The LPN said the resident did not like being touched or turned from her right side because of her pain. The wound care nurse (WOCN) was interviewed on 7/23/2020 at 8:54 a.m. She said skin assessments were performed weekly. After the assessments, interventions were implemented as needed and changed after wounds were noticed. Residents with wounds were seen weekly by the WOCN, unit managers and the wound care provider. Wound care treatments were changed as needed. The director of nursing (DON) was interviewed on 8/6/2020 at 5:45 p.m. The DON said Resident #10 preferred a particular position and wiggled out of the position changes and liked to lay flat. Staff have tried placing a pillow under her arm and put the elbow cup on but the resident wiggled out of that position. The DON stated it was difficult to balance the resident preferences and clinical needs. C. Pain 1. Observation and interview On 8/5/2020 at 10:37 a.m., RN #2 provided wound care for Resident #10's right elbow. The resident grimaced when the dressings were removed. RN #2 said the resident complained of pain, especially with movement, such as position changes. She said the resident had orders for [MEDICATION NAME] three times a day and liquid [MEDICATION NAME] every 12 hours as needed for pain. Resident #10 was interviewed on 8/6/2020 at 1:55 p.m. Using a dry erase marker and a white board, 'yes' or 'no' questions were asked. She indicated with head nods that changing position caused pain to her right arm and foot. She confirmed she did not like to change positions because of pain. 2. Record review The care plan, initiated 6/5/19, read that the resident was at risk for pain related to depression. Interventions included to assess for constipation, educate the resident to the cause of pain, management plan, expectations and possible side effects; monitor, record, and report complaints of pain or requests for pain treatment to the nurse; perform pain assessment per protocol; administer pain medication for doctors orders; and reposition for comfort. -The care plan failed to provide resident specific treatment for [REDACTED]. The facility, knowing the limitations for medication, failed to implement alternative pain management interventions. The August 2020 CPOs contained the following pertinent orders: -order start date 11/7/2019, apply pain menthol gel to posterior neck two times a day for neck pain/spasm -order start date 6/19/2020, administer [MEDICATION NAME] three times a day for pain. -order start date 7/16/2020, administer [MEDICATION NAME] sulfate as needed for severe pain every twelve hours. -order start date, 8/6/2020, apply [MEDICATION NAME] to the right shoulder daily for arm pain. The 8/3/2020 skilled evaluation note read that Resident #10 reported pain to her neck, elbow and ear multiple times a day. The August 2020 Skilled Evaluations revealed: -8/1/2020, resident had pain when dressings were changed. No education was provided. -8/2/2020, resident had no indications of pain. -8/3/2020, resident's facial expression indicated pain. The resident reported pain occurred multiple times per day to her neck, elbow and ear. The resident refused to be repositioned and resisted head and neck movements. No education was provided. -8/4/2020, resident reported pain of five out of 10 which occurred daily. The resident refused non-medication interventions. No education was provided. -8/5/2020, the resident reported pain of three out of 10 and had protective body movements. The resident reported pain occurred daily. No education was provided. The 8/3/2020 provider note read that the resident had recurrent pain issues increasing resistance to moving and repositioning. Taking liquid [MEDICATION NAME] and [MEDICATION NAME] for management and comfort but still has pain and discomfort, grimacing and pushing the provider/nurse away while trying to evaluate. Activity level remains quite low No alternative pain management interventions were added as resident continued to grimace and cry out when repositioned. 3. Staff interviews CNA #4 was interviewed on 8/6/2020 at 2:00 p.m. She stated they changed her position when she let them, however because it hurt the resident when staff provided position changes or incontinent brief changes. She said sometimes they do no not change her position because she cried. LPN #3 was interviewed on 8/6/2020 at 2:02 p.m. She said the resident did not want to be touched or turned on her left side because of her pain. She said the resident grabbed her arms, grimaced, tensed up and cried a lot because of the pain. She said the resident was given [MEDICATION NAME] three times a day and [MEDICATION NAME] every 12 hours if needed for pain. She said they recently received an order for [REDACTED]. The unit manager (UM) #3 was interviewed on 8/6/2020 at 2:09 p.m. She stated she did not know of interventions for pain other than [MEDICATION NAME] and [MEDICATION NAME]. She spoke with the physician's assistant (PA) and reported that he said the family was reluctant to give more pain medication because of the resident's history with narcotics and [MEDICAL CONDITION]. She reported that the resident was seen by the PA on 8/3/2020 and he had ordered a [MEDICATION NAME] for pain to the Resident #10's right arm. The (DON) was interviewed on 8/6/2020 at 5:45 p.m. The DON said the doctors worked with the resident's family regarding the resident's pain. The DON stated it is difficult to balance the resident preferences and clinical needs. D. Failed to update and ensure a resident specific care plan for communication 1. Observation On 8/5/2020 at 10:37 a.m., registered nurse (RN) #2 wrote messages to Resident #10 using a dry erase marker and a whiteboard. RN #2 stated the resident was very hard of hearing so they used a whiteboard to communicate. 2. Record review The communication care plan initiated on 6/5/19 and revised on 3/23/2020 read that the resident had a communication problem related to [MEDICAL CONDITION], stroke and ventilator dependence. The resident was able to answer simple yes/no questions. The intervention read that staff were directed to refer to speech therapy for evaluation and treatment. The communication care plan failed to include the use of a white board, sign language and cell phone to communicate with the resident based on observation, record review and staff interviews. The 8/3/2020 skilled evaluation note read that Resident #10 communicated with sign language and a white board. 4. Staff interviews CNA #4 was interviewed on 8/6/2020 at 2:00 p.m. She said staff used a whiteboard to write messages and the resident used a cell phone to write the response if it required more than a yes or no answer. The MDS Coordinator (MDSC) #1 was interviewed on 8/6/2020 at 2:55 p.m. He said he initiated care plans when residents arrived. He was not responsible for updating care plans. The NHA was interviewed on 8/6/20 at 3:10 p.m. He said the interdisciplinary team (IDT) discussed resident concerns and interventions and the team consisted of social services, resident care managers (unit managers), the therapy department, and the dietary manager. The NHA said he thought care plans were continually updated with new interventions. VII. Facility high incidence of in-house acquired pressure ulcers/injuries A. Facility policy and procedure The Pressure Ulcer/Skin Breakdown Clinical Protocol, last revised in April 2013, was provided by the nursing home administrator (NHA) via email on 8/6/2020. It read in part, A person at risk for pressure ulcers should be repositioned every two hours while in bed or at least every one hour whe(TRUNCATED)

Based on observations, interviews and record review, the facility failed to ensure a safe environment and adequate supervision to prevent accidents for two (#3 and #5) of three out of 10 sampled residents. The facility failed to identify a change of condition and implement fall preventative measures with her known history of falling to prevent the Resident #3 from sustaining a fracture to the left shoulder, which resulted in the resident being sent out to the hospital for treatment. The resident returned to the facility from the hospital wearing a sling requiring increased staff assistance and had an increased level of pain which required the use of pain medications. Furthermore, when the resident returned from the hospital fall measures were not implemented by the facility when she was found face down on the floor of her room and had passed away. The facility failed to implement fall preventive measures for Resident #5 who had an increased poor safety awareness because of his dementia that resulted in several falls in a short amount of time. Findings include: I. Resident #3 A. Resident status Resident #3, age 56, was admitted on [DATE] and passed away on 5/28/2020. According to the May 2020 computerized physician orders [REDACTED]. The 3/26/2020 minimum data set (MDS) assessment revealed the resident had no short and long term memory problems. The resident was independent with cognitive skills for daily decision making. No behavioral symptoms noted. She was independent with setup assistance with bed mobility, transfers, ambulation, and personal hygiene. She required supervision with one person assistance with dressing, eating and toileting. She was occasionally incontinent of urine and frequently incontinent of the bowel and no toileting program. She experienced occasional pain with use of as needed pain medications. She fell prior to admission but had no falls since admission. She received during the last seven days antibiotics and two days of opioids. She received oxygen therapy, hospice services and was on isolation/quarantine for being newly admitted . No restraints or alarms in place. B. Record review The care plan, initiated on 3/20/2020 and revised on 5/28/2020, revealed the resident was at risk for falls related to history of falling, [MEDICAL CONDITION], back/hip pain, hard of hearing (deaf to left ear, hard of hearing in right ear, psychoactive medicinal usage and oxygen dependence. -Interventions included she was independent and needed no staff assistance for transfers or toileting, she needed set-up assistance with bathing. Staff were to monitor for dizziness, drowsiness, clumsiness, memory loss, blurred or double vision, lack of energy, and forgetfulness due to anxiety medication. Staff were to monitor for mobility due to her history of falls. Staff were to monitor for dehydration risk due to a history of dehydration/electrolyte imbalance due to end stage liver disease. Staff were to give encouragement or assistance with her oxygen use. The 3/19/2020 Fall Risk Evaluation form read the following risk factors were associated with the resident required hands on assistance to move from place to place, used an assistive device, confined to a chair and oriented, date of admission less than three months, history of falling at least once to twice in the last six months and [MEDICAL CONDITION] medication use. The 4/17/2020 and 5/5/2020 progress notes revealed an order of [MEDICATION NAME] (an antibiotic used to reduce the absorption of ammonia) was to be given 4 times a day for 45 days due to a high ammonia level. The 5/4/2020 ammonia level laboratory results revealed the resident 's ammonia level was 54 with an abnormal result of critically high. The laboratory report showed a normal range of nine to 33. The 5/25/2020 at 12:04 p.m. progress note read that the resident had an elevated temperature and the resident was sleeping a lot but without respiratory symptoms. The 5/25/2020 at 1:26 p.m. progress note read that the hospice nurse visited with the resident and stated that she was aware of the resident 's mood being down, incontinent episodes and elevated temperature. The 5/26/2020 at 5:25 p.m. the hospice nurse was in to see the resident because she had abnormal lung sounds. The resident slept most of the day and said she was bored. The resident had a slight low grade temperature of 99.4 degrees Fahrenheit (F). The hospice nurse said that the low grade temperature was the resident 's baseline since admitting to hospice. The physician was notified and ordered a two-view chest x-ray, complete blood count (CBC) and basic metabolic panel (BMP). The 5/27/2020 at 6:24 a.m. progress note read that the resident was overheard yelling in the hallway for staff to help her. The resident was found lying in the bed stating that she had fallen twice to and from the bathroom. The physician was notified and ordered an x-ray of the shoulder. The resident 's left shoulder was assessed for pain, swelling and bruising. The resident was medicated for pain and neurological assessments were started. The 5/27/2020 Fall Risk Evaluation form read the following risk factors were associated with the resident having poorly fitting shoes, decrease in muscle coordination, medication use of anti [MEDICAL CONDITION]/antiepileptic, cathartics and narcotics, occasional incontinence of bowel and bladder. The 5/27/2020 at 4:11 p.m. progress note read, Patient fell on [DATE] in the early AM during shift change. Nurse (name of nurse) reported the patient fell unwitnessed when trying to get out of bed and go to the bathroom. Patient VS (vital signs) at 6:15 AM B/P (blood pressure) 123/80, Temperature 99.2, Pulse 109, Respirations were 24, shallow and irregular. (Clinic 's name) office called with a new order for x-ray and increase in PRN [MEDICATION NAME] (pain medication). Hospice notified and a hospice nurse came to the facility to evaluate the patient. Hospice nurse called the daughter. Left shoulder notable swelling and pain upon movement. Ice and pain medication administered per order. Xray result conclusion: [MEDICAL CONDITION] humerus and lateral displacement of the distal fracture fragment. Patient sent to hospital to be further assessed. The hospice (nurse) called the daughter to notify her that she has been taken off of hospice in case she needs surgery on her left arm. Patient returned with a sling for her left arm to stabilize the arm and decrease pain. Hospice notified. Daughter notified by hospice that the patient would need total shoulder replacement, the hospital would not operate on it acutely because it can be fixed outpatient. Immediately after returning to (facility name) from the hospital, when two assistants transferring from the bed to wheelchair to use the bathroom, the patient's body stiffened, lost pallor (a pale color of the skin), became unresponsive to verbal name, head rolled back to the left, with fixed gaze. VS 71/37 B/P, 89 Pulse, 92% O2 (oxygen) on 2L (liters) NC (nasal cannula). PRN (as needed) 10 mg (milligram) [MEDICATION NAME] sublingual administered. Event lasted for 45 seconds. After the event, VS B/P 87/55, 93% O2 on 2L NC, pulse 119, RR (regular respirations) 18, Temperature 97.1(F). Patient returned to her baseline and was able to respond to her name. Called (clinic name) office and head CT (CAT scan) ordered upon daughter with approval and pain medication changed to PRN [MEDICATION NAME] 0.5 ml (milliliters) (10 mg) sublingual Q (every) 3 hours for pain. Patient sent out to (hospital name) for head CT. The 5/28/2020 at 12:45 a.m. progress note read that the resident returned from the hospital after getting the head CT. The results were negative. The blood pressure remained low at 87/56 but the resident required an increase of oxygen to 4 liters with a pulse oximeter reading of 90%. The resident was not able to communicate to the nurse during the assessment due to pain so she was administered pain medications upon return from the hospital. The hospital prescribed a new [MEDICAL CONDITION] medication to begin the next day along with following up with a neurosurgeon. The daughter was notified of the resident 's return to the facility and provided the CT results. Until the decision could be made about surgery to the left shoulder, hospice services remained on hold. The nurse wrote that if the resident continued with a change in her condition then she would contact the physician for recommendations. The 5/28/2020 at 3:20 a.m. progress note read, This nurse found the resident on the floor face down. NC (nasal cannula) was off, the resident had shallow and irregular breaths. This nurse turned the resident over to obtain apical pulse, the resident was unresponsive. Resident shows lactation on the left eyebrow. RN from North unit was called by (name of CNA) CNA (certified nurse aide), RN (name of RN) (registered nurse) assessed the resident and announced ceased VS (vital signs). MD (medical doctor) was called and daughter (name of daughter) was notified. Coroner office was also notified. Daughter will be coming in to view the resident then the mortuary (name of mortuary) will be notified for release of body. Review of the resident 's medical record revealed there was no additional intervention put in place by the staff, including the interdisciplinary team subsequent to the resident 's fall on 5/27/2020. C. Staff interviews The nursing home administrator (NHA) was interviewed on 8/6/2020 at 3:52 p.m. He said, We review interventions such as falls. As a team we review falls and determine what interventions were put in place. We evaluate situations daily, not just one time. If what we did for a fall did not help we will change what we are doing and come up with a new plan. The restorative service director (RSD) was interviewed on 8/6/2020 at 4:30 p.m. She said Resident #3 came to the facility a few months ago and had poor safety skills. She said the resident had two falls, a fractured shoulder and high ammonia levels. She said the resident presented well and the resident thought she could do everything even though she had medical needs where she required assistance. She said it was hard to keep a resident safe when they seemed capable of doing ADL 's on their own. She said when someone is independent there is not much we can do, we can not watch them 24/7, and falls are unavoidable. She said Resident #3 returned from the hospital in May 2020 and additional interventions were not put in place because the resident had not been reviewed for her falls. She said she planned to evaluate the resident 's falls with the interdisciplinary team. She acknowledged the facility failed to identify the risk factors after the resident had fallen to prevent falls. She said she could not have prevented the resident from falling. The director of nursing (DON) was interviewed on 8/6/2020 at 6:00 p.m. She said Resident #3 came to the facility from California with her daughter but ended up in the hospital after the long drive. The resident had complex issues and it was a struggle to put things in place for her. The DON said the resident was independent with her activities of daily living. She stated the resident was younger than some other residents and had medical complications. She said after the last fall there on 5/27/2020, the resident had a change in condition. The interdisciplinary team planned to meet with the family the next day after the fall on 5/27/2020 to decide on a treatment plan with her being on hospice services previous to the hospitalization She said, There is a struggle with the population we care for and it is hard to get outside resources for interventions. There is a fall prevention committee/meeting once a month in the facility and they look at falls weekly. II. Resident #5 A. Resident status Resident #5, age 82, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 5/19/2020 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status score of three out of 15. He required one person assistance with a walker and wheelchair. He had an acute change in mental status with fluctuating behaviors present including; inattention, disorganized thinking and altered level of consciousness. He required extensive assistance of two persons with bed mobility, transfers and toileting. He required extensive assistance of one person with locomotion on the unit, eating and personal hygiene. He used a wheelchair as a mobility device. The resident had an unsteady balance moving from seated to standing positions, moving on and off toilet, and surface to surface transfers. The resident was coded to have fallen twice with injury and twice without injury since admission. The resident had received anti anxiety medications since admission. The resident received hospice services. B. Observations On 8/5/2020 at 9:00 a.m. Resident #5's roommate was observed in the hallway asking staff for assistance for his roommate. Resident #5 was observed in his room sitting in his wheelchair asking for assistance with his shoe in his lap. The call light was positioned on top of the bed. The resident moved himself in his wheelchair to the entrance way of the room but not to the hallway to get the attention of the staff. Resident #5 expressed the desire to be put to bed. On 8/6/2020 at 3:40 p.m. Resident #5 was sitting in his wheelchair that faced the television alone in his room. A plastic cup was crunched up and tipped over between his left leg and the wheelchair with water spilled from the cup onto the floor under his feet. Resident #5 leaned forward and was unable to reach for his shoes that were three feet in front of him. Resident #5 was asked how he asked for assistance from staff and where his call light was located. He used his right hand to touch the wheelchair brake on the right side of his wheelchair and used his thumb to press down on the brake handle while he said please three times. A touch call light was on the bed next to him within his arms reach however he did not acknowledge it was available. At 3:54 p.m. certified nurse aide (CNA) #1 entered Resident #5's room and said she would be right back and exited the room while the resident remained in his room alone. At 3:55 p.m. CNA #2 entered and then exited the resident's room while the resident remained in the room by himself a second time. At 3:56 p.m. CNA #2 exited the room with the resident in his wheelchair and took him to the television area across from the nurses station. C. Record review The care plan, last revised on 5/22/2020, revealed the resident had a personal history of falls and was at risk for further falls. Interventions included: -Limited to extensive two person assist with transferring; -Resident #5 was re-educated on the need to use the breaks before transferring in a wheelchair and/or to wait for staff to assist; -The resident started a check and change program for increased incontinence of bowel and bladder; -Non skid device was added to the wheelchair between the seat and the cushion; -A grab bar placed on the outside wall of the bathroom; -An additional grab bar was mounted inside the bathroom on the wall; -Staff was inserviced to not leave the resident's bed in a low position post fall; -The post fall assessment completed with implementations included the resident's wheelchair has an appropriate cushion, auto locking anti roll back breaks. Back of the chair has been positioned to lean back. Bilateral assist handle on bed, bed at transfer height, bolster mattress and touch call in place. -The resident utilizes bilateral assistive handles on wheelchair for mobility and transferring; -Restorative program updated to, Stand and transfer into stationary chair and back to wheelchair 5 times each in the common area, up to three times weekly for strengthening post fall. -Review and update fall risk assessment quarterly, post any fall and PRN. -Soft touch call light provided -Staff is serviced to keep call light placed on the left side of his body. -Rule out potential causes of fall such as infection, medication side effects, [DIAGNOSES REDACTED]. One-on-one person monitoring for the resident was not documented as an intervention on the care plan. The 4/11/2020 fall risk assessments revealed the resident was a high risk for falling with a score of 23 with concern of multiple falls. No other fall risk assessment was documented. The following post fall investigation reports and the Incident Audit Reports, included the incident status history, incident details, injuries, predisposing factors, witnesses, action/care plan revisions and notes. The audits reviewed from 3/31/2020 to 8/4/2020 revealed Resident #5 sustained 17 falls. The results of the audit revealed the following: On 3/31/2020 at 2:15 p.m. Resident #5 fell on his knees from his wheelchair onto the floor while eating lunch in the TV common area across from the nurses station. The resident was placed on alert charting every shift. The restorative service director (RSD) revised the incident document on 4/1/2020 at 9:39 a.m. It read that an in-service for the staff was to not let Resident #5 eat unattended in the TV room. On 4/11/2020 at 8:21 a.m. Resident #5 was found on the floor in his room trying to get into bed from his wheelchair. The post fall assessment dated [DATE] documented that the wheelchair had an appropriate cushion in place, locking anti-roll back breaks, the back of the chair had been tilted back, a grab bar was added outside of the bathroom, bilateral assist handles were installed onto his bed, the bed height was maintained at his transfer ability, a bolster mattress was in place, the bedside table was moved to the foot of his bed and the call light was replaced with a touch call light to reduce risk of injuries from falls. On 4/28/2020 at 5:00 p.m. Resident #5 attempted to transfer in the common area in front of the nurses station. The CNA could not get to the resident before he fell on his buttocks. The RSD added new therapy to include stand and transfer into a stationary chair then back again to the wheelchair. This was to be done five times each and up to three times a week for strengthening. On 5/2/2020 at 3:03 p.m. Resident #5 was found on the floor sitting in front of his bed in his room. He had four small skin tears. The intervention put in place was removing the bed cane from the side of his bed. On 5/5/2020 at 10:25 a.m. Resident #5 was found on the floor without injury in his room. The intervention included putting the resident on hospice services on 5/6/2020 due to falls, weakness and weight loss. On 5/13/2020 at 1:02 p.m. Resident #5 was found on the floor in his room and no injuries. No interventions were implemented after the fall. On 5/16/2020 at 10:27 p.m. Resident #5 was found sitting on the floor soiled with an incontinent bowel movement on him and in his wheelchair. The staff started a check and change program because of the increased incontinent bowel and bladder episodes. On 5/21/2020 at 9:13 p.m. Resident #5 slid from his wheelchair to the floor. The RSD on 5/22/2020 implemented a non-skid seat pad placed under his wheelchair cushion. On 5/22/2020 at 6:26 p.m. Resident #5 was found on the floor sitting in front of his wheelchair in his room. It read that the resident was placed on hospice due to his advanced dementia and weight loss with further decline expected. It read that the fall preventive measures that were in place were reviewed and kept in place after the last fall. On 5/23/2020 at 9:30 a.m. Resident #5 was found sitting on the floor in his room near the bathroom. No interventions were implemented after the fall. On 6/2/2020 at 6:15 p.m.; 6/17/2020 at 12:02 p.m. and 6/23/2020 at 2:00 p.m. were documented that the resident fell without injury, however no information about the falls and/or post falls were included in the audit. On 6/28/2020 at 7:40 p.m. Resident #5 was given medications for pain and anxiety, provided snacks before bed and one-on-one visit then fell on [DATE] at 2:27 a.m. when he was found on the floor on his knees in front of his wheelchair in his room. No interventions were implemented after the fall. On 7/5/2020 at 1:38 p.m. Resident #5 fell to the floor in the bathroom when he grabbed the bar by the toilet to stand up while the CNA was putting on her gloves. No interventions were implemented after the fall. On 7/11/2020 at 7:30 p.m. Resident #5 reached out his arms and leaned forward in his wheelchair and fell to the floor on his knees. No interventions were implemented after the fall. On 7/27/2020 at 4:17 a.m. Resident #5 was found on the floor in his room. It read, It sounds as though an aid had been assisting with dinner and she stepped out, then the resident may have been trying to get into bed and fell to the floor. Roommate turned the light on for the resident. (The roommate was) Unable to tell us what happened but he called. Even though interventions were put into place, the last intervention was dated 5/21/2020 of a non skid seat pad.The resident continued to fall seven more times after the last intervention was put into place. No new person centered interventions were added to prevent Resident #5 from falling. -In total Resident #5 fell 17 times within four months. D. Staff interviews The RSD was interviewed on 8/6/2020 at 4:20 p.m. She stated she led the fall interdisciplinary team (IDT) that consisted of the RSD, the unit managers and a staff member from each discipline including activities, dietary, nutrition, social services, the minimal data set coordinator (MDSC). She said the process for fall prevention included review in meetings with the fall IDT. Also, during stand up meetings every weekday morning involved information about falls in the last 24 hours, or over the weekend on Monday morning. The fall IDT meeting was held once a month to review falls, evaluate fall risk measures in place and update the care plan for the falls in the previous month that occurred. The electronic medical record system (EMR) contained the care plan with resident specific information that the CNA's did not have access to. The CNA's were notified of new or changed interventions by verbal education or given in verbal reports from the previous shift CNA's. The RSD said when Resident #5's falls increased due to the progression of his dementia and stated hospice care started on 5/6/2020. Fall risk prevention for the resident became challenging because of his poor solving and safety skills, as well as the COVID-19 pandemic because residents needed to stay in their rooms. Fall prevention interventions included one-on-one staff monitoring close to the nurses station, safety devices added to his wheelchair, and involved the activities department to implement the resident with new activities he enjoyed. Resident #5 did not have one-on-one monitoring because residents were to stay in their room due to COVID-19 mandates. The director of nursing (DON) was interviewed on 8/6/2020 at 5:30 p.m. She said fall intervention review was an ongoing process and is held once a month with the fall IDT. The pharmacy department was included in the fall IDT meetings held once a month as part of The Quality Assurance and Performance Improvement (QAPI) meetings. Resident safety became difficult because of the frequent infection control regulations updates mandated by The Center for Medicare and Medicaid Services (CMS) for the COVID-19 pandemic. The behavioral health population that the facility served was a challenge to provide for all the resident specific needs and supervision. She said fall prevention measures for Resident #5 was implemented by the facility that included equipment placed in his surroundings, outside family visits and other activities with the activities department. She said Resident #5 began hospice care because his problem solving skills and safety awareness worsened relating to [DIAGNOSES REDACTED]. However, according to the care plan and interviews the one-to-one did not happen and the resident continued to fall.

Based on observations, record review and interviews the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for one (#65) of five residents reviewed for nutrition out of 50 sample residents. Specifically, the facility failed to reassess Resident #65's nutritional status after he removed his gastrostomy tube ([DEVICE]) and experienced a significant weight loss of 19.2% in six months. I. Facility policy and procedure The facility Nutrition Assessment Policy, revised (MONTH) 2011, was provided by the nursing home administrator (NHA) on 11/12/19. It read, in pertinent part, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current initial assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: Usual body weight; current height and weight; a description of the resident's usual intake and appetite; a history of reduced appetite or progressive weight loss or gain prior to admission; current clinical conditions and recent events that may have affected a resident's nutritional status and risk factors; the resident's usual route of intake; food preferences and dislikes; and estimate of calorie, protein, nutrient and fluid needs; whether the resident's current intake is adequate to meet his or her nutritional needs; and special food formulations. Individualized care plans shall address to the extent possible: the identified causes of impaired nutrition; the resident's personal preferences; goals and benchmarks for improvement; and time frames and parameters for monitoring and reassessment. II. Resident status Resident #65, age 66, was initially admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 9/19/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required set up assistance with eating. The resident's height was 68 inches and weight 171 pounds. The assessment revealed the resident's weight loss was significant and he was on a prescribed weight-loss regimen. The resident had moisture associated skin damage with a nutrition or hydration intervention to manage skin problems. III. Record review The comprehensive care plan, revised 9/23/19, revealed the resident had a history of [REDACTED]. His tube feedings were discontinued at his own request and he showed significant weight loss from one month and six months ago. The goal was the resident would not show significant weight changes over 90 days and protein stores would be within normal limits when checked. Interventions included diet as ordered, encourage resident to fill out the weekly menu with his preferences, monitor weight per protocol, offer snacks as needed and at night, and provide vitamin and protein supplements as ordered. Additionally, the comprehensive care plan, revised 9/26/19, revealed the resident was admitted with pressure ulcers to his left heel, left ischial tuberosity, right outer ankle, and potential for further pressure ulcer development. He had a history of [REDACTED]. He also had moisture associated skin damage to his buttocks. Interventions included air mattress, monitor skin daily, and see nutrition care plan focus. However, the nutrition care plan failed to address the resident's nutritional status risks with skin breakdown. The weights and vitals record revealed the following: - 5/7/19 resident's weight was 200.5 pounds - 5/21/19, 193 pounds - 6/4/19, 192 pounds - 7/1/19, 187 pounds - 7/5/19, 186 pounds - 8/5/19, 181 pounds - 9/6/19, 170.5 pounds (5.8% weight loss in one month after [DEVICE] removal) - 10/4/19, 168 pounds - 10/15/19, 164.5 pounds - 10/23/19, 159.5 pounds - 11/5/19, 162 pounds (19.2% weight loss in 6 months) The most recent Registered Dietician Assessment, completed on 12/28/18, documented the resident received tube feedings at night due to inadequate intakes for meeting estimated needs for wound healing. He had presence of skin breakdown at the time of the assessment. His food intake averaged 76-100%. The most recent Food Preferences assessment, completed on 9/3/18, revealed the resident liked potatoes, open faced turkey sandwiches, and burritos. He disliked cold cut sandwiches and salads. The resident expressed he was unhappy with the food and had difficulty swallowing some foods. The assessment did not indicate which foods were difficult to swallow. His usual body weight was documented as 175 pounds. The 8/17/19 nursing progress notes revealed the resident removed his [DEVICE] and refused to have it replaced. There was not a recent Registered Dietician Assessment with the resident's current nutritional status. The 9/9/19 skin and wound assessment revealed the resident acquired moisture associated skin damage (MASD) on his coccyx on 9/6/19, and the dietician was notified of the new wound. The 11/6/19 skin and wound assessment revealed the resident was educated on protein intake for wound healing. This education was 2 months after the wound developed and the resident experienced 10.5% weight loss since his [DEVICE] was removed. The 9/26/19 weight warning nutrition note revealed the resident experienced a 5.8% weight loss. The note documented the resident had a prescribed weight loss to reduce his overall intake. The note was made 20 days after the resident experienced significant weight loss and 19 days after the resident acquired MASD on coccyx. The facility failed to reassess the resident's nutritional status after significant weight loss occurred and he acquired a wound on his coccyx. The 10/25/19 weight warning nutritional note revealed the resident experienced 20.6% weight loss in 6 months. It revealed the resident reached his ideal weight and dietary was to update his food preferences to increase intakes. Review of the food preferences assessment revealed the facility failed to update the resident's food preferences after severe weight loss was identified on 10/25/19. IV. Interviews Resident #65 was interviewed on 11/6/19 at 2:16 p.m. He said he had lost a lot of weight recently because the food was gross and he didn't want to eat it. He said he would eat more food if the facility served him something he liked to eat. The registered dietician (RD) was interviewed on 11/12/19 at 9:30 a.m. She said the resident refused all supplements for increased protein intake. She said the resident accepted strawberry ice cream and he liked to eat meat and potatoes. She said the resident did not like to ask for foods and he needed to be offered foods he liked for him to eat it. She said if he was served food he didn't like then he would not eat the meal. She said nursing staff should offer alternative options if they notice he didn't eat the food, but she did not know how often he was offered alternatives. The RD said the resident told her he wanted to lose weight, however she did not document this or assess for a prescribed weight loss plan. She said she monitored his weights monthly until he got to his desired weight loss but she did not determine what his caloric intake needs were. The RD said she completed nutrition assessment annually or if the resident had a change of condition in his nutrition. She said she did not reassess the resident after he removed his [DEVICE] on 8/17/19 because the resident had been at the facility for a long time and she had regular conversations with him about his food. She said his low calorie intakes would affect the healing of his wounds on his coccyx and he did not have any wounds before it was removed. She said the resident had education about protein intakes and his wound healing in the past so she did not provide new education to him until 11/6/19 (see above wound and skin assessment). Resident #65 was interviewed again on 11/12/19 at 10:13 a.m. He said he never wanted to lose weight and his desired weight range would be 170 to 180 pounds. He said he was aware low intakes would affect his wounds but he did not like the food that was served to him. The director of nursing (DON) was interviewed on 11/12/19 at 10:41 a.m. She said the resident doesn't like high calorie supplements and the dietary staff talked to him about his food preferences. She said his tube feeding was to maintain nutrition for wound healing and wound prevention. She said he had mentioned wanting to lose some weight to her, but she said she did not know what his goal weight would be. She said she would expect the RD to follow body mass index (BMI) standards for a safe body weight and the RD should calculate his estimated daily calorie and protein needs. She said she would expect the RD to complete an assessment after the resident's [DEVICE] was removed to ensure adequate intakes were met. The dietary manager (DM) was interviewed on 11/12/19 at 10:31 a.m. She said she obtained resident meal preferences upon admission or if they expressed preferences to her then added them to the resident's meal tickets. She said the RD did all weight loss monitoring but she encourages larger portions if she is aware of weight loss in a resident. She said she was aware Resident #65 experienced significant weight loss, but she has been short staffed in the kitchen and has not had a chance to meet with him about his meal preferences yet.

Based on record review and interviews, the facility failed to ensure the highest practicable quality of care for one (#1) out of six sampled residents. Specifically, the facility failed to: -Prevent a fall with injury during a transfer; and -Follow up with medical providers accurately and in a timely manner for assessment and treatment of [REDACTED]. These failures contributed to delayed treatment for [REDACTED]. Findings include: I. Resident Status Resident #1, age 55, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/20/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15 with no behaviors exhibited. She required extensive or total assistance of two or more staff members for all activities of daily living (ADLs). II. Record Review A. Care plans An activities of daily living (ADL) care plan initiated on 8/6/13 and revised on 5/27/19 read that the resident had a self care deficit due to [DIAGNOSES REDACTED]. Interventions read that the resident was a total assist of two staff members for transferring with a mechanical lift. A fall care plan initiated on 7/10/13 and revised on 5/27/19 read that the resident was a fall risk related to gait/balance problems, history of falls, lack of impulse control, choosing not to use mobility aids, poor judgement and [DIAGNOSES REDACTED]. The care plan did not include that the resident had a fall during a transfer, and did not include new or specific interventions to minimize fall risk during transfers. B. Incident report An incident report, initiated on 5/25/19 and revised on 5/28/19 read that Resident #1 slipped out of the mechanical lift sling and certified nurse aides (CNAs) lowered her to the ground. She did not hit her head. The resident was assessed by a registered nurse (RN) and was noted to have swelling and complain of pain to her right knee. The physician and family were notified and an order for [REDACTED]. The report read that it was determined the resident's mechanical lift sling was too big for her and the resident was provided with a smaller size. C. X-Ray report The resident's ordered X-rays were taken on 5/25/19 at approximately 8:30 p.m. The results were received by the facility on 5/26/19 at 3:50 a.m. and indicated that fluid around the resident's knee was suspicious of a non-displaced fracture. The report instructed the facility to correlate clinically and that follow-up was recommended. D. Progress notes On 5/26/19 at 5:48 a.m. a nursing note read that the resident's X-ray results returned with no fractures noted from the fall and that the resident was sleeping without complaints or problems noted. On 5/26/19 at 6:27 a.m. a nursing note read that the X-ray results were faxed to the resident's physician and the nurse practitioner (NP) after-hours line, and an attempt was made to reach the on-call physician on the urgent line but was unsuccessful, and another attempt would be made as soon as possible. On 5/26/19 at 6:42 a.m. the resident was medicated with 650 mg of [MEDICATION NAME] for right hip and right pelvic pain (see pain assessments/ratings below). On 5/26/19 at 9:17 a.m. a note read that the nurse had spoken with the NP and the X-ray results were faxed for further review. On 5/26/19 at 12:25 p.m. the resident was medicated with 650 mg of [MEDICATION NAME] for pain to her right knee. On 5/26/19 at 4:14 p.m. a nursing note read that the resident was tearful and anxious during the morning shift and that the resident had verbalized a decrease in pain level after medication. Swelling was still noted to the resident's right knee where her pain was localized, and the NP was aware of the resident's condition and radiology results, with staff to continue to monitor. On 5/27/19 at 6:54 a.m. the resident was medicated with 650 mg of [MEDICATION NAME] for pain and not feeling well. On 5/28/19 at 7:29 a.m. the resident was medicated with [MEDICATION NAME] 5-325 mg for pain. On 5/28/19 at 10:24 p.m. the resident was medicated with [MEDICATION NAME] 5-325 mg for pain to her right leg. On 5/30/19 at 9:57 a.m. a nursing note read that the resident was unable to go to an ordered facility for a CT scan and a new order was received to send the resident to the hospital for a CT scan of her right knee. On 5/31/19 at 7:52 a.m. the resident was medicated with [MEDICATION NAME] 5-325 mg for complaints of pain to her right knee. On 5/31/19 at 10:59 a.m. a nursing note read that the soonest available appointment at the hospital for a CT scan was on 6/6/19 at 10:30 a.m. The nurse spoke to the NP to obtain orders to send the resident to the emergency department for the CT scan related to right knee pain and swelling and the X-ray not showing any fractures. On 5/31/19 at 11:24 a.m. a nursing note read that the resident was lowered to the floor from the mechanical lift sling over the past weekend and that interventions of ice and rest had not been effective. The resident's condition had stayed the same since the incident and what made the condition worse were movement of the right leg, and what made the condition better were [MEDICATION NAME] pain medication. Medication changes that had occurred in the past week included adding the [MEDICATION NAME] pain medications. On 5/31/19 at 5:59 p.m. a nursing note read that the resident returned from the emergency department and the CT scan showed a closed [MEDICAL CONDITION] end of the right femur. The note continued that the NP made changes to the [MEDICATION NAME] medication order to [MEDICATION NAME] 5-325 mg twice a day scheduled and once a day as needed. The resident returned with a knee brace for stabilization, strict non-weight bearing orders, and orders to follow up with an orthopedic consultation. On 6/3/19 at 12:59 a.m. the resident was medicated with [MEDICATION NAME] 5-325 as needed for increased knee pain with repositioning On 6/4/19 at 1:14 p.m. the resident was medicated with [MEDICATION NAME] 5-325 as needed for pain prior to going to the orthopedic appointment. On 6/5/19 the resident went to the hospital to have surgical repair to her right femur and knee completed, and returned to the facility on [DATE]. She continued to require pain medications for leg and knee pain. E. Physician orders [REDACTED]. On 5/25/19 at 1:41 p.m. a verbal order was received for a STAT right pelvic, right femur, and right tibia/fibula X-ray related to pain and swelling post fall. The (MONTH) 2019 TAR revealed this order was fulfilled on 5/25/19 at 3:25 p.m. On 5/27/19 at 6:20 p.m. a verbal order was received for an orthopedic consult for right knee pain and swelling. The (MONTH) 2019 TAR revealed that this order was fulfilled on 5/28/19 at 4:38 a.m. though there was no other documentation of the order being fulfilled in the resident's medical record. On 5/28/19 a verbal order was received to refer the resident to imaging for a CT scan of her right knee due to swelling and inconclusive x-rays. There was no indication in the resident record (progress notes, MAR indicated [REDACTED]. On 5/29/19 a verbal order was received to refer the resident to imaging for a CT scan of her right knee due to swelling and inconclusive X-rays. There was no indication that this order was fulfilled. On 5/30/19 a telephone order was received to refer the resident to imaging for a CT scan without contrast for right knee due to swelling and inconclusive X-rays. Review of the resident record showed that there was no attempt made to schedule a CT scan until 5/30/19 which was five days after the resident's fall and two days after the first order was written. Additionally the resident did not have the CT scan performed until 5/31/19 which was six days after the resident fell . F. Pain medication orders and pain scales On 5/25/18 an order was received for [MEDICATION NAME] 325 mg; give 650 mg by mouth every four hours as needed for elevated temperature or pain. The resident's MAR indicated [REDACTED]. On 5/27/19 at 6:30 p.m. an order for [REDACTED]. This order was discontinued on 5/31/19 at 6:40 p.m. On 5/31/19 at 7:00 p.m. an order for [REDACTED]. On 5/31/19 at 6:45 p.m. an order for [REDACTED]. According to the resident's MAR, nursing staff was to assess the resident's pain level on a scale of zero to 10 twice a day. Her pertinent pain scale ratings were as follows: For the month of (MONTH) 2019, before the resident's fall, the pain scale ratings were consistently zero/10. 5/25/19 zero/10 a.m. and zero/10 p.m. 5/26/19 four/10 a.m. 5/27/19 four/10 a.m. and nine/10 p.m. 5/28/19 five/10 a.m. 5/29/19 three/10 a.m. 5/31/19 five/10 a.m. 6/1/19 four/10 a.m. 6/2/19 two/10 p.m. 6/3/19 two/10 a.m. and three/10 p.m. 6/4/19 three/10 a.m. 6/5/19 five/10 a.m. III. Interviews The restorative nurse (RSN) was interviewed on 7/24/19 at 12:20 and stated that it was determined that the mechanical lift sling the resident was using at the time of the fall was too big. After the fall, on 5/28/19, a new sling assessment was completed and the resident was provided with a smaller size and different color settings for hooks that hold the sling to the machine. She continued to state that a root cause for the sling being too big was not found. She stated that the resident's name was on the sling and the CNAs knew what size and settings to use in case they needed to get an extra sling for the resident if the resident's was damaged or needed cleaning. She said that all nursing staff was re-educated on mechanical lift transfers on 6/4/19 after the incident. CNA #1 was interviewed on 4/24/19 at 1:45 p.m. She stated that she did not know how the resident slid out of the mechanical lift sling and that the resident already had the sling under her when the transfer was started. She stated that there were two CNAs performing the transfer and that when the resident slid out, she was caught and lowered to the ground as softly as possible in an attempt to prevent or minimize injury. She stated that the sling sizes were identified by the color around the border and the hook positions were set by color and were determined by the RSN to ensure proper positioning of the resident. She stated that the resident did not start to report pain until after returning from the dining room. The director of nursing (DON) was interviewed on 7/24/19 3:15 p.m. She stated that the resident fell out of the sling because it was determined to be too big. She stated that all residents were assessed by the RSN for appropriate mechanical lift sling sizes and settings and that the information was documented in the resident's room. She stated that facility was following physician orders [REDACTED]. She confirmed that there was no documentation of attempts to follow up with the physician or NP related to the resident's condition not improving. She also confirmed that there was no evidence of attempts to schedule the ordered CT scans in a timely manner. She stated that the X-ray results were not read correctly and that the staff did not follow up on scheduling the CT scan timely. She stated that the resident would have been treated sooner and might not have had so much pain if the X-rays had been read correctly and the follow up and scheduling would have been timely. Resident #1 refused interviews on multiple attempts on 7/24/19. Attempts were made on 7/24/19 to reach both the resident's physician and nurse practitioner by phone and were unsuccessful.

Based on observations, record review and interviews, the facility failed to ensure proper interventions were in place for the prevention of falls with major injury for two (#2 and #3) of three residents investigated for falls. The facility failed to implement new interventions after Resident #2 had a fall on 12/27/18 where he was lowered to the floor. Additionally, Resident #2 had a fall on 1/7/19 and the facility failed to implement interventions after identifying that Resident #2 was wearing improper footwear and the wheelchair locks were not working. Finally, Resident #2 fell on [DATE] which caused trauma to his face and a head injury with cerebral hemorrhage. The facility did not identify that Resident #2 needed to go to the hospital until family requested sending the resident to the hospital where the head injury was identified. Subsequently, the resident was discharged to hospice and did not return to the facility. Resident #3 fell on [DATE] and suffered pain in the right shoulder and on 1/18/19 the nurse practitioner (NP) documented the resident suffered a proximal right humerus fracture and assistance needs changed, she required two person assistance and a mechanical lift for transfers. Subsequently, due to decreased mobility, on 2/6/19, the resident developed a pressure ulcer to her right heel and on 2/13/19 the resident developed a pressure wound to her coccyx. - Resident #3 fell two other times, on 2/24/19, where she was lowered to the floor as a result of not using the Hoyer Lift and on 3/9/19 where she slid out of her wheelchair. Findings include: I. Facility policy and procedure The (MONTH) 2010 Falls clinical protocol policy, provided by the director of nurses (DON) on 3/11/19 at 1:56 p.m. revealed, in part, For an individual who has fallen, staff will attempt to define possible causes within 24 hours of the fall .If the cause of the fall is unclear, if the fall may have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help identify contributing causes .the staff and physician will identify pertinent interventions to try and prevent subsequent falls and to address risks of serious consequences of falling. II. Resident #2 status Resident #2, age 73, was admitted on [DATE] with readmission on 5/2/18. According to the face sheet, [DIAGNOSES REDACTED]. The minimum data set (MDS) assessment dated [DATE] showed the resident was cognitively intact with a brief interview for mental status (BIMS) score 14 of 15. Functional status indicated resident was an extensive assist with one person assist for transfers and supervision with one person assist for walking in the room. A. Family interview Family member #1 was interviewed on 3/11/19 at 9:15 a.m. Family member #1 said the resident had a bad fall and they received a call from unit manager (UM) #1. UM #1 said the resident had a fall with a lot of blood. She said, the resident looked very swollen and was black and blue. His eye was swollen shut. The resident was non-verbal and unable to swallow. Family member #1 said the doctor declined to see the resident stating I don ' t have time. The family called 911 later that day because the resident did not seem right. The family said it appeared like he had more than one fall. There was a lot of impact. B. Record review The care plan, dated 6/25/18, revealed the resident was at risk for falls related to generalized weakness, [MEDICAL CONDITION] disorder and dementia. Interventions included: Assist handle to both sides of bed for mobility and transfers; fall was isolated; Isolated event- resident will be offered a reacher .which he has refused stated no, I already have one; Keep call light within reach; monitor for decline or improvement in mobility; had been on an ambulation program in an attempt to strengthen lower extremities and decrease fall risk; resident is on palliative care, continued decline is anticipated. Fall was isolated as resident was lowered to the floor; resident refused a quad cane stating he trips over them. He does utilize a one point cane; rule out potential causes of fall such as infection, medication side effects, [DIAGNOSES REDACTED]. The care plan was not updated to include more recent falls and interventions. The certified nurse aide (CNA) kardex (written communication for the CNAs regarding resident care) revealed in part, Mobility: Resident is independent and can require extensive assistance with locomotion on/off unit. Review of the interdisciplinary nursing progress notes revealed the following: -1/31/19: Spoke with daughter who reported that her dad had a fall last week. No documentation to support this. Interviewed this resident and he stated that he was in the bathroom and the riser tipped. -2/1/19: Doctor . was in this facility earlier today around dinner time. This writer told him that the residents family would like to talk to him about their dad ' s medications and that they want him to assess resident. The doctor said he was busy and to have on-call from palliative care handle the situation .several calls to palliative care about medications, residents status and possible hospitalization . New orders received for anti-anxiety medications. Review of the fall incident reports revealed the following: -12/27/18: Description - CNA reported that during the transfer from the bed to the wheelchair the resident stood and turned away very quickly, sat on the arm of the wheelchair. It moved and he began to fall. She then held onto him and lowered him to the floor on his right side. Immediate action: assisted back to the wheelchair. Injuries: no injuries. Predisposing factors: during transfer was marked. Intervention (as marked by the DON): Resident has been experiencing some terminal agitation. Medication in place to assist with terminal diagnosis. Resident stated I moved too fast. Gait belt was in place and resident was lowered to the floor. No additional interventions were added. -1/7/19: Description: Resident yelled for CNA. CNA observed resident on the floor on his back facing the door. CNA called out for nurse. Upon arrival observed resident on his back on the floor. Had another CNA get a registered nurse (RN). RN assessed resident for range of motion (ROM), neuros, pain and injury. Resident stated that he was reaching for his shoes on the floor. Started to fall forward and decided to sit on the floor. Immediate action: assessed for injuries before moving. Staff assisted resident up in wheelchair. Injuries: no injuries observed. Predisposing factors: Wheelchair locks not working; weakness/fainted; improper footwear. Intervention (as marked by the DON): Isolated: resident continues to wish to provide personal care as able. Will encourage him to gauge how he is feeling and request assistance as needed. There was no mention of interventions related to the wheelchair locks not working and the improper footwear observed. -2/1/19: Description: Called to room as resident was noted on the floor laying in his right side with his legs extended straight. Noted a pool of blood on the floor under residents head. Full assessment done. Pressure applied to nose and to left eye. ROM within normal limits for the resident. Complained of rib pain. Resident was unable to describe, increased confusion noted. Immediate action: first aide to stop the bleeding. Full assessment done to assess for injuries. Bed placed in low position as resident had increased agitation noted. Injuries: no injuries noted. Predisposing factors: gait imbalance and ambulating without assist. Intervention (as marked by the DON): Restorative to add onto ambulation in attempts to increase resident strength to reduce the risk of injuries. Review of the hospital records summary located in the resident ' s chart, dated 2/2/19 revealed the following: -Chief complaint: presents with fall -Resident .with dementia, [MEDICAL CONDITION], history [MEDICAL CONDITION](stroke) with left sided deficits, and palliative care, who presents with a fall this morning. Apparently, patient had an unwitnessed fall at this skilled nursing facility, had obvious trauma to the face, and has been confused and delirious since then. When his family arrived at the nursing facility, they were concerned and asked that he be transferred to the hospital for further workup. In accordance with the patients wishes, family does not want to perform any aggressive interventions. -Labs: Hemoglobin- 6.4 low (normal range: 14-18 g/dl (grams/deciliter); Hematocrit- 21.6 low (normal range- 40-54 g/dl). -Final impression: Traumatic right-sided [MEDICATION NAME] hemorrhage with loss of consciousness; fall; [MEDICAL CONDITION]; left orbital fracture, closed. Review of the hospital discharge summary, dated 2/4/19 revealed: primary diagnosis- head injury. Hospital course- Presented after a fall at his living facility. Patient was found to have a traumatic head injury with cerebral hemorrhage and was minimally responsive with ongoing agitation. Patient was admitted for control of symptoms as family was adamant they did not want any aggressive interventions. He was made comfort care and hospice eval was ordered. Patient will be discharged to hospice. (The resident did not return to the facility) C. Resident interviews Resident #4 was interviewed on 3/11/19 at 2:17 p.m. He was the one who found the resident after the fall. He said he came to the room. The door was shut and the call light was on. He did not know how or why the door was shut. He opened the door. Resident #4 saw him lying on the floor. I knew right away he fell . He backed out of the room and yelled, I need help. D. Staff interviews UM #1 was interviewed on 3/11/19 at 12:36 p.m. She said this resident had left-sided deficits from a previous stroke. He needed long term care and had poor safety skills. He wanted to toilet himself. He was able to call for help. He fell frequently. With his latest fall, his nose was bleeding. He had terminal agitation. She said they got the bleeding to stop and had a staff member watching him. He had a black eye. She said she provided the resident first aide. They gave him a shower to see if there were any other areas. She did not think he had any fractures. She said she did not think he needed to go to the hospital. RN #2 was interviewed on 3/11/19 at 1:22 p.m. She found him on the day of his fall. He was on the floor. He was very agitated. She said she had worked in the facility for approximately three months. and had never seen that kind of a fall. He was swollen. She did not know what happened. She received a report from the CNA and asked the CNA to call the supervisor. RN #3, palliative nurse, was interviewed on 3/11/19 at 1:44 p.m. She said she got a call from the UM #1 informing her this resident had a fall with a lot of blood loss. They found him on the floor next to the bed and there was blood everywhere. RN #3 saw the resident after they showered him. He had a large hematoma to his left eye. He was agitated. He looked comfortable. The staff had given him [MEDICATION NAME] and [MEDICATION NAME]. She said he was not sent to the hospital by the facility staff because he was comfortable and it was not in line with the goals of his care. She coordinated with the nurse practitioner (NP). The residents family called 911 so that he could be evaluated at the hospital. The DON was interviewed on 3/11/19 at 3:07 p.m. After discussing the 1/7/19 fall, the DON said she thought the improper footwear meant he was wearing plain socks. She confirmed there was potential with the wheelchair locks not working. It could have contributed to his fall. With the improper footwear, he had the potential to slide. The process, after a fall, was to notify the palliative nurse who would notify the physician. -At 4:44 p.m. when asked about the lack of interventions, she said they had an action plan for falls. It was started on 2/8/19. They have a new fall tracking form. She noticed most of the falls had occurred in resident rooms. She knew this resident had a hematoma and nose bleed with his most recent fall but had not seen him. III. Resident #3 status Resident #3, age 91, was admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], showed the resident had moderately impaired cognition with a BIMS score eight out of 15. Functional status indicated resident was an extensive assist with two person assist for transfers. A. Family interview Family #2 was interviewed on 3/11/18 at 5:04 p.m. Family said the resident fractured her shoulder. She wished she had not fractured her shoulder because the resident would not get out of bed and would not eat. She was active before her fall. B. Observations Resident #3 was observed on 3/11/19 at 12:11 p.m. She was in her bed. The bed was in low position. A fall mat was beside her bed with a bedside table on top of the mat. -At 1:19 p.m., the resident was in bed sleeping. The bedside table was partly on the mat with two wheels on the mat and two wheels off of the mat. -At 5:04 p.m., she was in her bed, awake. Family at bedside. C. Record review Review of the fall care plan, 10/15/18, revealed the resident was at risk for falls related to poor communication/comprehension, poor insight/judgement due to [DIAGNOSES REDACTED]. The CNA kardex revealed in part, Transfers: resident is currently transferring with a Hoyer lift. Review of the fall incident reports revealed the following: -1/15/19: Description- Resident lying on her back with feet by her bed and head by the sink. Wheelchair was behind the resident and the wheels were not locked. Resident reports falling when trying to get into her wheelchair .She reports hitting her back on something when she fell . Immediate action: Resident assessed, reports pain in right shoulder and has no ROM in right shoulder. No bruising or red areas .Stat x-ray ordered. Injuries: no injuries. Predisposing factors: confused, impaired memory, ambulating without assist. Intervention (as marked by the DON): Will request therapy to assess resident for transfer status. Restorative reports she was refusing. No additional interventions put into place. -2/24/19: Description: CNA #1 went to transfer resident; not knowing she was a Hoyer lift. While trying to transfer, resident weakened and CNA lowered her to the floor. No injuries noted. Immediate action: Resident assessed for injuries. Transferred back to bed by two staff members. Injuries: no injuries observed. Predisposing factors: blank. Intervention (as marked by the DON): fall has been reviewed by the interdisciplinary (IDT), staff to be educated on how to transfer the resident. -3/9/19: Description: This nurse was called into the dining room to assess resident. Resident was reaching for something and slid out of her chair onto the floor. Fall was witnessed by many people in dining room as there was an activity going on. No injuries noted. Predisposing factors: impaired memory, using wheelchair was marked. Intervention: restorative to assess wheelchair for positioning. Review of the NP notes revealed: -1/18/19: Patient very unfortunately suffered a fall the other day and suffered a proximal right humerus fracture .now requiring a 2-person assist with any position changes and per CNA who knows her well, she is not eating or drinking very much at all. -1/24/19: Patient reports: fairly consistent intense pain from arm. Feeling a little better presently. -2/6/19: Resident is recovering from a fracture of humerus. With decreased mobility, she developed a pressure wound to her right heel. -2/13/19: Staff reported heel wound is resolving .about a week ago, a new wound developed on the coccyx. D. Staff interviews RN #4 was interviewed on 3/11/19 at 12:55 p.m. He did not know much about this resident. He thought she transferred with a lift and fell and fractured her humerus. She did not use the call light. He was the RN who assessed the fall. There was something noticeably wrong with her shoulder. She was sent to the hospital. They could not fix it because it was an old repair that had fractured again. She had a mat and a bolster mattress. She was not getting out of bed as much and had developed a pressure ulcer. The DON was interviewed on 3/11/19 at 3:29 p.m. Regarding her 1/15/19 fall, it would be the responsibility of the staff to make sure her wheelchair was locked. She said potential interventions could have been anti-rollbacks. She said they had started an action plan that included some education. CNA #1 was interviewed on 3/11/19 at 4:11 p.m. With regards to the 2/24/19 fall, she said she was sent over from another hall. She should have printed off the kardex. The other aide told her to see if she could get this resident up. She used to be a stand pivot. I thought that was how she transferred. She said the kardex was a new thing they started since around January. She said she did not know how to print off the kardex. Before the kardex, they would ask the staff. I changed the hall at the last minute. She did not get report on everyone, so she assumed everyone transferred the same. The DON was interviewed again on 3/11/19 at 4:36 p.m. She said the CNAs should know how to transfer a resident by looking at the kardex. She said they finished educating the staff and they could print the kardex out. We did education for all staff. They had recently gotten access to the print function.

Based on observation, record review and interviews, the facility failed to provide the necessary catheter care for three of 40 sample residents (#12, #76 and #194). Specifically, the facility failed to provide prompt and effective assessment of a urinary catheter obstruction for resident #76 and provide catheter care according to standards of practice and facility policy for residents #12 and #194. The findings include: 1. Resident #76 Resident #76, age 75, was admitted to the facility on [DATE] from the hospital. The face sheet of the same date indicated the following Diagnoses: [REDACTED]. On 4/24/14 the [DIAGNOSES REDACTED]. The 5/14 computerized physician orders [REDACTED]. The 5/14 orders included an emergency order for Invaz 1 gm IM nightly for urinary tract infection. According to the FDA-federal drug administration web site www.fda.gov/Drugs/DrugSafety/ <http://www.fda.gov/Drugs/DrugSafety/>, the use of the Invaz is a penem antibacterial indicated in adult patients for the treatment of [REDACTED]. Ancillary orders of the same date included a Foley catheter size #16 to be changed the 27th of every month and as needed for dislodgement or occlusion. A separate order for Foley catheter care every (q) shift beginning 12/31/13 was documented. an order for [REDACTED]. The quarterly minimum data set ((MDS) dated [DATE], indicated that the resident had no cognition loss and scored a 15/15 on the brief mental mini exam (BIMS). The resident was able to make needs known and had never rejected cares. Section G of the document indicated that the resident was dependant on a mechanical lift for all transfers and required extensive staff assistance with toileting, hygiene and transfers. Section H of the document indicated that the resident had an indwelling urinary catheter. The document also documented that the resident had a [DIAGNOSES REDACTED]. The resident received scheduled pain medication daily as indicated in section J of the MDS. The care plan dated 8/13/13 and updated 5/13/14 indicated that the resident was care planned for the use of a Foley indwelling catheter with the risk of infection. Some of the staff interventions included: providing routine catheter care, reporting obstructions or possible infection to the medical provider and change/irrigate the Foley as needed. The last intervention documented on the resident's care plan indicated that the facility nursing staff should observe the resident's Foley tubing for kinks. Interviews: On 5/27/14 at approximately 10:30 a.m., an interview with the resident was conducted. The interview indicated the following: -The resident had an indwelling urinary catheter for [MEDICAL CONDITION] and [MEDICAL CONDITION]. -The resident was a retired registered nurse and nursing instructor and was able to guide and direct her cares regarding her urinary Foley catheter. (See above; her BIMS indicated the resident had no cognitive losses and both short and long term memory were intact.) -On May 3, 2014 at approximately 4:30 p.m., the resident stated that she began having a lot of pain in the bladder region and from previous experience she thought her urinary catheter tubing might be kinked. She stated the pain was different from every day aches and she knew that she needed her catheter changed. -The resident stated that she was in a lot of pain from the catheter not working properly and had to request additional pain medication ([MEDICATION NAME]) to relieve the pain. The resident stated the medication did not help much and she needed to have the catheter removed and a new catheter put in. -She reported to multiple staff including the unit CNA (Certified Nurse Aide), the unit staff nurse and the house supervisor on 5/3/14 from approximately 4:45 p.m. that her catheter tubing was kinked and not working. She stated in her profession as a nurse, she had become educated and had acquired the knowledge that if a urinary catheter was not draining or working properly, the situation could become a medical emergency if not resolved. The knowledge caused her anxiety and she had to request a medication for anxiety. -The resident used her private cell phone to call the house supervisor and request assistance with her urinary catheter on 5/3/14 because the facility staff nurse #1 working on the resident's unit was not responding to the resident's request to have her catheter changed. The house supervisor was on another unit in the facility and responded approximately 45 minutes after the resident spoke to her on the phone. -The time frame from when the resident first notified the nursing staff that her catheter tubing was kinked and she was uncomfortable until when the resident's catheter was changed was approximately three hours. The resident stated it felt like a long time especially when she was in a great deal of discomfort. Interviews with the director of nursing (DON) were conducted on 6/2/14 at approximately 10:45 a.m. and 2:13 p.m. The interviews revealed the following: -The nurse on the unit did not irrigate the catheter until she got directions from the house supervisor a few hours after the resident called for assistance and communicated that she was in pain. -The expectation of the DON was that any floor nursing staff responds to a resident's complaint of pain and catheter complaints as soon as possible (ASAP). -All nursing staff should document in the resident's medical record concerning cares and treatments provided to a resident. If there is a change of condition or a situation that requires calling a medical provider there should be documentation in the resident's medical record. -A complete assessment of the resident's urinary catheter and tubing should have been done when the unit nurse answered the resident's call light and request for assistance with her catheter was made. -The provider should have been made aware of the resident's complaint of pain related to her kinked catheter tubing per the facility policy. -A resident should not have to use their personal cell phone to locate staff for assistance especially with a medical concern. A lot of residents do use their cell phones to call staff but it is not expected that residents use their phones to call for staff assistance. -If a nurse is taking care of a resident with a urinary catheter, the nurse should know how to troubleshoot problems regarding urinary catheters. -A portion of the skill competency checklist that all facility nursing staff is expected to participate and show competencies in, includes urinary catheters. The unit staff nurse was signed off by the director of nursing as competent in Foley catheter care and assessment. -The resident has been in the facility for approximately three years and the grievance surrounding the lack of care for the catheter on 5/3/14 was the first grievance that the resident had submitted. -The facility policy for catheter care documents the guidelines for assessing and managing possible urinary catheter obstruction. According to the policy, the nurse did not follow the facility policy by not reporting the resident's pain and tenderness to the bladder region. -The unit staff nurse had not been in serviced or educated about the inadequate assessment, reporting her findings to the physician and documenting her actions with regards to the cares she delivered to sample resident #76. Interview with the west unit manager (LPN-Licensed Practical Nurse) was conducted on 6/2/14 at approximately 4:00 p.m. The interview revealed the following: -If a resident had an indwelling urinary catheter and complained of pain or discomfort, the first step a nurse should do is assess the resident and the catheter. Then the nurse should use the bladder scanner to determine if the resident had retained urine. -If the resident had a provider order to flush or replace the urinary catheter, then the nurse should attempt the less invasive procedure first of flushing the tubing. Then if that did not relieve the obstruction, the Foley should be replaced. -The resident's medical provider should be notified of any difficulties the resident is having with their urinary catheter. -The nurse should document in the progress notes any cares, treatments or complications that occurred during the encounter with the resident. Record Review: Facility policy Catheter Care dated 10/10 indicated that the purpose of the policy was to prevent catheter-associated urinary tract infections. The section "Complications" indicated the responsibility of the facility nursing staff when a resident complained of catheter complications was to report any complaints the resident may have of tenderness and pain in the bladder area to the medical provider. The area of the policy labeled "Managing obstruction" indicated that the facility nurse should notify the physician and then change the catheter. The resident filed a grievance with the facility on 5/9/14, stating that the nurse on duty on the evening of 5/3/14 did not know how to troubleshoot the pain and the catheter problems she was having. According to the grievance, the facility nurse did not assess the resident's catheter and complaint of pain related to a possible kink in the catheter tubing. The resident was required to use her own cell phone to contact the house supervisor who was on another unit in the facility to request assistance with her urinary catheter. The facility developed a care plan specific to the resident's grievance regarding catheter needs. The document indicated that response to the resident's request for a nurse to evaluate her catheter/tubing should be ASAP. Some other interventions for the resident should her catheter have become clogged included attempting to flush the catheter, repositioning the catheter and changing the catheter if the resident was in excruciating pain. A review of the nursing progress notes for the date of 5/3/14, the date of the resident's catheter problems and additional need for pain and anxiety medication was completed. The review indicated that staff nurse had not documented on the resident's Foley catheter and tubing concerns. There was no notation the facility had contacted the medical provider to communicate the resident's concern and pain. A review of the nursing progress notes dated 5/8/14, documented the resident was started on a third antibiotic urex-for urinary tract infections. This was five days after the resident complained of staff not assessing her urinary catheter and tubing. A review of the resident's Medication Administration Record [REDACTED]. The resident was also medicated with a federally controlled schedule four medication for anxiety related to the malfunction of her urinary catheter. A review of the physician provider notes dated 5/22/14 indicated that the resident had recent re-current urinary tract infections [MEDICAL CONDITION] with two separate organisms responsible for the infections. In the body of the document the physician documented the resident's re-current UTIs are complicated by immobility, Foley catheter and history of UTIs. 2. Resident #194 Observation on 5/30/14 at 11:45 a.m., revealed one certified nurse aide (CNA #46) provide pericare for resident #194. The resident was in bed on his back and had a Foley catheter attached to the side of the bed. There was urine and sediment in the catheter tubing. The CNA turned and repositioned the resident twice while lifting the catheter tubing above the level of the bladder. The urine back flowed towards the bladder. Review of a facility policy dated 10/10 titled urinary incontinence clinical protocol revealed "the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent urine in the tubing and drainage bag from flowing back into the urinary bladder". On 5/27/14 at 3:22 p.m., the unit manager (UM north) revealed the resident had [MEDICAL CONDITION] due to a stroke [MEDICAL CONDITION] and had a Foley catheter. Review of the resident's record revealed he was admitted on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. His most recent MDS assessment dated [DATE], disclosed he was unable to complete the BIMS (brief interview for mental status). There was no coding for short or long term memory problems; however, he was coded as being independent in decision making. He required extensive assist with bed mobility; was totally dependent on staff for transfers, toilet use and personal hygiene. Under the bladder and bowel section, he was coded as having an indwelling catheter and urinary continence not rated. Physician orders [REDACTED]. Care plans -4/30/14 Resident has indwelling catheter for [MEDICAL CONDITION] due to [MEDICAL CONDITION]. Interventions included check tubing for kinks and patency, make sure that tubing is over the leg to avoid any trauma with pulling; Monitor for signs of infection, let the nurse know if resident has blood, sediment, cloudy or foul smelling urine, or complains of burning sensation on urination or pain; place an indwelling Foley catheter, provide the routine care and change as needed and ordered by MD; position urinary drainage bag below level of bladder, let nurse know if resident has any leaking around the tubing; resident has a catheter per physician order; resident is catheterized monthly by the licensed nurse (LN) for urine, please notify LN if resident has pain, discomfort; see resident care tasks for care of catheter equipment. The north unit manager (NUM), disclosed on 5/30/14 at 11:25 a.m., was informed of the findings during pericare and transfer for 2 (#12 and #194 - see below) residents. She said she would provide training immediately. On 5/30/14 at 2:35 p.m., CNA #46 (observed above) said she had seen nurses lift the catheter tubing to make sure urine drained into the catheter bag before starting cares. She said she did not know why. She said she did not know that the catheter bag and tubing was not supposed to be raised above the level of the bladder. The director of nursing (DON) said on 5/30/14 at 2:38 p.m., she heard from the unit manager regarding catheter cares. She said they provided training for CNA #46. 3. Resident #12 On 5/30 at 11:10 a.m., observation disclosed transfer, pericare and wound care provided for resident #12 by 2 CNAs #46 and #32 (certified nurse aide). The resident was seated in a geri-chair and transferred to his bed using a Hoyer lift. There was urine in the catheter tubing. The resident was placed in bed and the catheter bag was hooked to the foot of the bed. Also in the room during the pericare were a licensed practical nurse (LPN #7) and the NUM. The CNAs repositioned the resident during the pericare and lifted the bag causing the urine to back flow towards the bladder. The resident had a suprapubic catheter. Review of resident #12's record disclosed he was admitted on [DATE] and 7/3/12, with [DIAGNOSES REDACTED]. His most recent MDS assessment dated [DATE], disclosed he scored 15 out of 15 on the BIMS indicating his cognition was intact. He was totally dependent on staff for bed mobility, transfers, toilet use and personal hygiene. He was coded as having an indwelling catheter and urinary incontinence was not coded. Physician orders [REDACTED]. Care plans were requested from the director of nursing on 5/30/14 around 12:00 p.m., and were not provided prior to the end of the survey. The Director of Nursing (DON) revealed on 6/2/14 at 2:38 p.m., her expectation for staff was to keep the catheter bag and tubing below level of bladder and empty it prior to moving the resident.

Based on closed record review, hospital record review and interviews, the facility failed to ensure one of 23 sample residents (#23) was provided necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, the facility failed to monitor the resident's urinary output, failed to provide timely assessment, failed to adequately monitor and failed to notify the physician of the resident's acute declining change of condition. The resident was transferred to an acute care hospital where she was diagnosed with [REDACTED]. The findings include: Twenty-eight year-old resident #23 was originally admitted to the facility from a hospital on [DATE] with [DIAGNOSES REDACTED]. The resident was briefly discharged to a hospital on [DATE] with a necrotic toe and returned to the facility on [DATE] after treatment at the hospital. On [DATE], the resident experienced a decline in medical condition and was discharged from the facility to the hospital on [DATE] where she died on [DATE]. The MDS (Minimum Data Set), dated [DATE], indicated the resident was comatose. The resident was totally dependent on two staff for bed mobility. The MDS indicated that the resident was totally dependent on staff for all other ADLs (activities of daily living). The resident was incontinent of bowel and had a Foley catheter in place. The resident had full loss of movement in all four extremities. The resident's closed record was reviewed on [DATE], then again on [DATE] through [DATE]. The resident experienced respiratory distress for over an hour and half without assessment or physician notification while a Licensed Practical Nurse (LPN) evaluated the resident with a fever over 101.6 degrees Fahrenheit (F). The LPN was unable to get an oxygen saturation level reading for this resident, who had an artificial airway in place and was oxygen dependent. The resident was discharged from the facility to a local hospital emergency room (ER) at 12:20 p.m. on [DATE], when the LPN notified the RN who assessed the resident at 10:30 a.m., and discharged the resident to a local hospital at 12:20 p.m. The facility's failures contributed to the delay in treatment for [REDACTED]. The resident was treated with intravenous (IV) antibiotics, IV fluids, and high levels of oxygen therapy to address the multi-system decline in medical condition. The resident died at the hospital on [DATE] and the primary cause of death was listed as, "Septic shock with gram-negative bacteremia due to urinary [MEDICAL CONDITION]." The facility policy for Foley Catheter management was requested and provided by the Director of Nursing (DON) on [DATE]. Review of the policy revealed no requirements for documentation or measuring Foley catheter urinary output on a regular basis. On [DATE] at 2:00 p.m., the DON was asked to clarify the policy on Foley catheter output monitoring. The DON clarified the policy and stated, "Certified Nursing assistants (CNAs) empty the Foley catheter every shift, the only time they report urinary output to the nurse is if there is no urinary output ...CNAs have been trained to monitor output ...as small, scant, or poor ...I can't describe small, maybe less than a cup ...Only time output is recorded in ccs, would be if a physician specifically ordered for input and output ...say with someone with [MEDICAL CONDITION] ...There is no policy to regularly monitor Foley catheter output." Physician computerized orders (CPO) and Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"[MEDICATION NAME] 3 ML 1 VAIL [MEDICAL CONDITION] EVERY 6 HOURS PRN (as needed) ...SHORTNESS OF BREATH [MEDICATION NAME] (Tylenol) 650 MG Enteral EVERY 4 HOURS PRN ...GENERALIZED PAIN/FEVER ...TYLENOL 325 MG 2 TABS (tablets) PER PEG TUBE Q (every) 4 HRS (hours) PRN PAIN/TEMP (high temperature) ...OXYGEN AT 8 L/MIN (liters/minute) WITH 30% HUMIDIFICATION CONTINUOUSLY VIA TRACHE." Review of the resident's generic care plan, dated [DATE], indicated the resident had potential for respiratory distress related to (r/t) trach(eostomy) use. The goal, dated [DATE], indicated the resident's respirations would remain at ,[DATE] per minute and the resident would be without respiratory distress through the next review date. The approaches for the care plan indicated, in pertinent parts, "MONITOR VITAL SIGNS INCLUDING PULSE OXIMETRY (pulse ox/O2 sats) WHEN HAVING EXCESSIVE SECRETIONS OR SOB (shortness of breath) ...ADMINISTER OXYGEN ...AS ORDERED BY THE M.D. (physician) CHECK PULSE OXIMETRY AS ORDERED." However, review of physician orders revealed no orders regarding how often the pulse ox was to be checked. Review of nurses' notes, dated [DATE] though [DATE], revealed no daily or consistent documentation of the resident's pulse ox. In fact, there was no nursing documentation between [DATE] and [DATE], when the resident experienced acute respiratory distress and was discharged to the hospital. The care plan approaches further read, "MONITOR RESIDENT FOR SIGNS OR SYMPTOMS OF TROUBLED BREATHING OR IN DISTRESS, NOTIFY NURSE (Registered Nurse) IF RESIDENT IS HAVING LABORED BREATHING, CYANOSIS, OR SHORTNESS OF BREATH, THE NURSE WILL NOTIFY THE FAMILY AND MD." Review of the resident's Foley catheter use care plan, last updated on [DATE], revealed in pertinent parts, "AT RISK FOR [MEDICAL CONDITION] TRAUMA AND INFECTIONS DUE TO USE OF Foley CATHETER DUE TO [MEDICAL CONDITIONS] AND WOUND." The goal for the care plan was the resident's Foley catheter would remain patent, without signs and symptoms of infection or urinary trauma through [DATE]. The approaches to the care plan included, "MONITOR URINARY OUTPUT PER FACILITY PROTOCOL. MAKE SURE ...DRAINAGE BAG IS EMPTIED EACH SHIFT AND AS NEEDED." However, review of the facility policy revealed no indication for regular monitoring of urinary output for a resident who had a [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. The LPN notes, dated [DATE] at 9:00 a.m., read in pertinent parts; "Upon entering resident's room, found resident cyanotic, and with large amount of emesis on chest and around trach. Unable to obtain blood pressure (BP) reading, radial pulse 150, RR (respirations) 64, unable to get a pulse ox reading (O2 saturation reading). Began cleaning patient up of emesis. Repositioned resident, checked oxygen (no recorded reading of oxygen sats readings) [MEDICAL CONDITION] removed approx (approximately) 10 cc cloudy, light brown orange colored fluid, no plugs noted. Oxygen saturation did not improve." There was no baseline oxygen sat reading, as the LPN indicated she was unable to obtain a reading or any further readings during that hour and a half. The LPN note further read, in pertinent parts, "Resident currently on 6 L O2." Although physician orders indicated the resident, who was experiencing respiratory distress at the time, was to be administered 8 L/min of oxygen with 30% humidification continuously via trach, there was no indication the physician was notified the resident was on a reduced amount of oxygen prior to the time or during the time the LPN found the resident and stayed with the resident from 9:00 a.m., through 10:30 a.m., a period of at least an hour and half. At that time, the RN was first notified and saw the resident. The RN then increased the resident's oxygen to 10 L/min and provided additional artificial (bagged) ventilation for the resident. The LPN notes, dated [DATE] at 9:00 a.m., further read, in pertinent parts, "Axillary (under the arm) temperature 101.6 (degrees F), administered 650 mg Tylenol via g tube, since resident was actively having a BM (bowel movement)." It was unclear if the resident was administered Tylenol at 9:00 a.m., when the LPN evaluated the resident with a fever, or at 11:00 a.m., as review of the MAR indicated [REDACTED] The LPN notes, dated [DATE] at 9:00 a.m., further read, in pertinent parts, "Very little urine output from Foley catheter, dark amber colored and with sediment noted. Resident is visibly distressed, other staff members (per LPN interview on [DATE] at 10:30 a.m., she clarified the staff as two certified nursing assistants), arrived to assist me (LPN) care for the resident (between 9:00 a.m. and 10:30 a.m.)." During that time period, no RN had assessed the resident and there was no evidence found to show the physician was notified of the resident's condition. At 10:30 a.m., after the RN was notified, the RN initiated an assessment for the resident, who was in respiratory distress, without a BP, with a fever, with "little" urinary output. Appropriate interventions were not initiated during that hour and a half time period. The RN notes, dated [DATE] at 12:00 p.m., read in pertinent parts, "Called to resident's room at approx 10:30 a.m. Resident ...(with) labored breathing and cyanosis, [MEDICATION NAME] given, lung sounds coarse, able to cough up thin watery orange/brown tinged phlegm from trache, suctioned X 3 (three times) ...no improvement." It was unclear if the resident had an O2 sat reading at this time or if O2 sats could not be obtained. No baseline was provided. "Resident bagged ...pulse ox improved to ,[DATE] %...(with) O2 turned up to 10 L/min ...Residents pulse ox ... (went down to) 70's when not bagged." There was an hour and a half hour delay in the assessment and implementation of treatment for [REDACTED]. The RN notes dated, [DATE] at 12:00 p.m. for 10:30 a.m., further read, in pertinent parts, "HR (heart rate) in ,[DATE]'s. Call placed to Dr ....office ...report given and orders received to send resident to ER (emergency room ) for eval (evaluation). 911 called an ambulance transported resident to (hospital name) @12:20 p.m.," more than three hours after the onset of respiratory distress, a high fever and "very little" urinary output. The resident's hospital stay record was requested, was provided and reviewed while on survey. The Hospital ER physician notes, dated [DATE], revealed history of present illness as: DYSPNEA which stated at 7:00 a.m., that morning while the resident was at the facility. ER Physician notes read, in pertinent parts, "Arrived by ambulance. Historian -EMS (Emergency Medical Services) ...DYSPNEA, started today at 7:00 (7:00 a.m.) and is still present ...It was gradual in onset and has been constant. The dyspnea is severe ...EMS picked up the resident from the ....facility. O2 sats were 56% on room air ...Staff (facility staff) think pt possibly aspirated [DEVICE] food" ...PHYSICAL EXAMINATION ..."[MEDICAL CONDITION] respiratory distress with retractions and tachypnea ...Rhonchi present bilaterally ...Chest x-ray: Questionable left infiltrate." Hospital triage physician notes, dated [DATE], revealed EMS assessment and interventions prior to arrival at the ER. The physician notes read, in pertinent parts, "History onset (on and off since 7:00 a.m. per EMS) ...EMS report reviewed ...Oxygen administered (by EMS). Assisted ventilation with bag-valve mask. Suctioning performed. BP ,[DATE]. HR: 80. RR: 52. O2 saturation: 56 % room air when they (EMS) arrived on scene (at facility) ...assisted resp via ambu ...no blood samples or medications given." Blood work was drawn and reviewed by the ER physician on [DATE]. The ER Physician notes read, "PROGRESS AND PROCEDURES ...Pt was seen by me on arrival ...critically ill. Septic. Prob (probable) urinary or pneumonia ...CLINICAL IMPRESSION: Septic ...Pneumonia ...Urinary tract infection." Nurses' notes, dated [DATE] at 12:58 p.m., read in pertinent parts, "Airway breathing assisted by Ambu ...Oxygen increased to 15 liters and 100% by bag valve mask." The referring physician notes, dated [DATE], read in pertinent parts, "REASON FOR CONSULTATION: Gram-negative bacteremia with septic shock, likely source is urinary tract infection ....The patient was hypertensive with a temperature of almost 105 degrees F yesterday ([DATE]) and was taken to the emergency room where she was noted to be in shock. Hypertensive [MEDICAL CONDITION] significant leucocytosis (elevated white blood cell count) on CBC ...CT of the abdomen was obtained ...the findings was a marked distended urinary bladder with even hydroureters secondary to urinary obstruction. The Foley catheter was removed, and a blood clot came out. The urinary bladder drained over 1 L (liter) spontaneously. She was covered with board-spectrum antibiotics, and this morning blood cultures are growing gram-negative rods, as are urine cultures. The antibiotics have been modified to imipenem (anti-infective) plus [MEDICATION NAME] ...The urine also has gram-negative cocci." The consulting physician notes on that date further read, in pertinent parts, "IMPRESSION: Gram-negative bacteremia with septic shock from an obstructive urinary tract infection. It was a bladder outlet obstruction relieved with Foley catheter change." The resident died at the hospital on [DATE]. Hospital discharge notes read, in pertinent parts, "CAUSE OF DEATH: Septic shock with gram-negative bacteremia due to urinary [MEDICAL CONDITION]. ADDITIONAL CONTRIBUTING Diagnoses: [REDACTED]." On [DATE] at 12:30 p.m., the facility Unit Manager Registered Nurse (UM) was interviewed. The UM stated that on [DATE], she was called at 10:30 a.m., for assessment of the resident's condition. The UM stated, "They did not call me earlier than 10:30 a.m. I was first notified at 10:30 a.m. ([DATE]) and I went down there and she was not doing well. I do not know what happened before then (10:30 a.m.) ...I took vital signs and she was in distress ...When I got there she was not bagged (assisted with ventilation via Ambu-bag). I connected the Ambu-bag for helping her with breathing ...I increased the oxygen ...I was in a meeting before then and I was not aware of the situation before then (10:30 a.m.) ...I would have expected to see a pulse ox ...I was not aware there was no pulse ox reading before I arrived ...I was in a.m. meeting ...I found her in respiratory distress ...Her O2 sats were below 60%...I was not there before 10:30 a.m., I cannot speak for the LPN." The UM further stated that she called the physician and called 911, and the resident was transferred to the hospital on that date at about 12:20 p.m. On [DATE] at 10:30 a.m., the LPN, who worked with the resident on [DATE] during that day shift, was interviewed via telephone. In the interview, the LPN stated, "I went into her (resident #23) room at approx 9:00 a.m. I saw some fluid coming out of her trache. I immediately cleaned her up ...I went into room at approximately 9:00 a.m. for data collection ...I did not get or document actual data ...It was stressful ...between 9:00 a.m. and 10:30 a.m. ...I was trying to get vital signs (VS) ...I was unable to get a reading of blood pressure ...I grabbed two CNAs to check VS ...The CNAs were trying to get VS but were unable to ...She (resident #23) was very cold and I was trying to warm her up ...I am not licensed to assess ...so I was cleaning up the resident and suctioning ...She (resident #23) had a fever ...I should have gotten someone licensed (RN) to assess but there were no nurses (RNs) when I run out there (hallway, nursing station) at 9:00 a.m. ...I found a CNA ...It did not occur to me that there was a meeting (RN meeting) ...I am a fairly new LPN ...I was stressed out ...I had never taken care of this patient ...I did the best I could to take care of the patient ...It is not in my scope of practice ...From the time I saw the resident to the time I called the nurse (9:00 a.m. to 10:30 a.m., a period of one hour and a half), I could not get a reading for a pulse ox and a blood pressure ...Her (resident #23) eyes were fixed ...I did not know her baseline ...she did not move ...I was in the room with two CNAs, I felt I did everything I could until the nurse arrived." The resident had an artifical airway, was ventilator dependent and she was receiving oxygen at 6 L/min instead of the ordered 8 L/min. Furthermore, the resident had a fever and had minimal urinary output. There was no indication or documentation of the resident's urinary output during the change of shift or any time before 9:00 a.m., that morning. Prior to documentation of the 9:00 a.m., [DATE] nurse's notes, the most recent entry was on [DATE]. EMS had reported, to the admitting hospital physician, that they were informed by the facility the resident started experiencing respiratory decline at 7:00 a.m., on [DATE], rather than 9:00 a.m. On [DATE] at 10:00 a.m., the DON was interviewed. The DON acknowledged the facility failed to follow physician's orders regarding oxygen administration of 8 L/min oxygen. The DON stated the resident had no orders for input or output monitoring, therefore, her urinary output was not measured or documented. The DON further acknowledged the LPN did the best within her scope of practice. The DON stated the pulse ox monitoring for ventilator dependent residents was to be done as ordered by the physician. The DON stated during suctioning (of a trach) staff were to monitor pulse ox. However, the DON reported the nurses did not have to document, when resident tolerated suctioning. On [DATE] at 2:30 p.m., the Medical Director Physician (MDP) was interviewed. The MDP stated, "Standard hospital policy in general is to check daily pulse ox at least once a shift and document somewhere ...I agree there is no adequate documentation showing adequate oxygenation on [DATE] between 9:00 a.m., and 10:30 a.m. ...Documentation is inadequate...Data is missing I agree. There is not ideal documentation ...I can see we have a problem ...I prefer to get some pulse ox reading ...I see no documentation for an hour and a half (between 9:00 a.m. and 10:30 a.m. when the resident experienced cyanosis)." The facility failed to appropriately monitor the resident's urinary output, by [DATE] at 9:00 a.m., the resident had a fever, "very little" urinary output. There was no indication found to show she had any urinary output earlier that day or on any day shortly before [DATE] at 9:00 a.m. CT (type of x-ray) test results revealed septic shock from an obstructive urinary tract infection. The bladder outlet obstruction was relieved with Foley catheter change at the hospital. The facility's failure to monitor, timely assess and intervene contributed to the resident's death on [DATE].