Every finding on record at Peaks Care Center, The

Based on observations, record review and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to:-Ensure dietary staff washed their hands and changed single-use glove use appropriately during meal service;-Ensure meat was thawed according to safe food handling practices;-Ensure staff wore hair nets during food preparation; -Ensure the microwave was maintained in good repair and safe condition; and,-Ensure staff maintained sanitary conditions in the kitchen when eating at a food preparation table. Findings include:I. Hand hygieneA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 4/16/26. It revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands.(2-301.15)B. Facility policy and procedureThe Food Preparation and Service policy, revised November 2022, was provided by the nursing home administrator (NHA) on 4/9/26 at 4:33 p.m. It revealed in pertinent part, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food.C. ObservationsDuring a continuous observation of the lunch meal on 4/8/26, beginning at 11:30 a.m. and ending at 12:49 p.m., the following was observed in the kitchen:At 11:35 a.m. cook (CK) #1 began assembling meal plates for residents. At 12:13 p.m. CK #2 wore oven mitts over single-use gloves to remove the pot roast from the oven, placed the pot roast in the hot holding area, and removed the oven mitts.At 12:13 p.m. while wearing the same single-use gloves, CK #2 worked at the grill preparing burgers. CK #2 then turned and moved to the cold preparation area and began preparing a sandwich. CK #2 prepared a ham and cheese sandwich with the same gloved hands. CK #2 reached into a bag of chips while wearing the same pair of gloves, picked up chips with his gloved hand, and placed the chips on a plate and served them to the resident.At 12:14 p.m. CK #2, while wearing the same gloves he opened cans of tomato soup.At 12:15 p.m. CK #2, while wearing the same gloves, flipped burgers and handled buns on the grill.At 12:16 p.m. CK #2, while wearing the same gloves, he picked up a meal ticket.At 12:16 p.m. CK #2, while wearing the same gloves, he used the microwave and heated food.At 12:17 p.m. CK #2, while wearing the same gloves, he picked up a clean plate.At 12:17 p.m. CK #2, while wearing the same gloves, he removed a hamburger from the grill, picked up the hamburger bun with his gloved hand, placed the hamburger on a bun on the plate, and served the plate to a resident.At 12:18 p.m. CK #2, while wearing the same gloves, he picked up a meal ticket.At 12:18 p.m. CK #2, while wearing the same gloves, he picked up cheese from the bag and placed it on the bun with his gloved hand.At 12:19 p.m. CK #2, while wearing the same gloves, he picked up a bottle of mayonnaise and spread it on the bun for the burger.At 12:20 p.m. CK #2, while wearing the same gloves, picked up ham and placed the ham on a cutting surface. CK #2 held the knife in his right hand and held the ham with his left hand to cut the ham. CK #2 then picked up the ham with his gloved hands, placed the ham on a slice of bread, and served the plate to a resident. The gloves were wet from moisture on the outside when CK #2 placed the food on the plate.At 12:22 p.m. CK #2 removed his single-use gloves and donned (put on) a new pair of gloves without performing hand hygiene.At 12:25 p.m. CK #2, while wearing the same gloves, worked at the grill and prepared a ham and cheese sandwich.At 12:26 p.m. CK #2, while wearing the same gloves, picked up a meal ticket and placed it in the preparation area, removed his gloves, and donned another pair of gloves without performing hand hygiene.At 12:27 p.m. CK #2 plated food to be served to three residents.At 12:31 p.m. CK #1 removed his gloves and donned a new pair of gloves without performing hand hygiene.At 12:31 p.m. CK #1, while wearing the same gloves, picked up a meal ticket, plated food, and served the plate to a resident.At 12:32 p.m. CK #1 removed his gloves, picked up meal tickets, and brought the meal tray cart into the kitchen.At 12:33 p.m. CK #1 donned a new pair of gloves without performing hand hygiene and handled food and a plate.At 12:34 p.m. CK #1 plated pot roast with carrots and potatoes, added gravy, covered the plate, and placed the plate on a cart.At 12:35 p.m. using the same gloved hands CK #2 placed raw hamburger meat, buns, and cheese with his gloved hands on the grill to begin preparing a hamburger. At 12:36 p.m. CK #2, while wearing the same gloves, picked up onions, pickles, and lettuce with his gloved hands and placed the items on the hamburger, placed a plate cover over the plate, and placed the plate on a cart.At 12:37 p.m. CK #2, while wearing the same gloves, dropped a bun on the floor while preparing a hamburger, picked up the bun from the floor by the top portion, discarded the bun, did not change gloves, and continued preparing a hamburger.At 12:40 p.m. CK #2, while wearing the same gloves, picked up a plate, placed a grilled cheese sandwich on the plate, and served the plate to a resident.At 12:41 p.m. CK #2, while wearing the same gloves, picked up a quesadilla from the grill, placed the quesadilla on a cutting board, and cut the quesadilla with a knife with his gloved hands.At 12:42 p.m. CK #2, while wearing the same gloves, used a towel from the sanitizer bucket to wipe the food preparation area. CK #2 did not change gloves and did not perform hand hygiene. CK #2 then picked up a tortilla, placed the tortilla on the grill, and added cheese with his gloved hands. At 12:45 p.m. CK #2 discarded his gloves, washed his hands for 10 seconds and donned a new pair of gloves.D. Staff interviews The dietary manager (DM) was interviewed on 4/8/26 at 2:45 p.m. The DM said the staff working in the kitchen were expected to wash their hands anytime they changed tasks and when there was risk for cross contamination. The DM said gloves were worn when handling food and must be changed during service and between tasks. The DM said she reminded the dietary staff to wash their hands and multiple in-services had been completed on hand hygiene. The DM said the staff must perform hand hygiene when moving from dirty to clean tasks. The DM said hand hygiene was important to prevent spread of bacteria and residents from getting sick. CK #3 was interviewed on 4/8/26 at 3:57 p.m. CK #3 said he had worked at the facility for almost a year and was ServSafe certified (food safety certificate). He said he last took the food safety course about four years ago. CK #3 said he received hand hygiene and infection control training when he started working at the facility. He said there was an upcoming training. CK #3 said he washed his hands every time he entered the kitchen and when he changed single-use gloves. CK #3 said he always wore gloves when he handled food and cleaned and should change them after each task. CK #3 said he changed his gloves after completing each task. CK #3 said after making a hamburger he washed his hands and donned a new pair of gloves before moving to the cold bar to prepare a sandwich. CK #3 said if he touched his face, clothing or another surface he discarded gloves, washed hands and donned new gloves.The registered dietitian (RD) was interviewed on 4/9/26 at 1:25 p.m. The RD said employees working in the kitchen were required to wear gloves while serving food. The RD said staff should have washed their hands and put on new gloves if gloves became contaminated or after completing a task. The RD said when staff left the kitchen and returned, they were required to wash their hands and put on new gloves. II. Thawing frozen foodA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 4/16/26. It revealed in pertinent part, Time/temperature control for safety food shall be thawed: under refrigeration that maintains the food temperature or completely submerged under running water. (3-501.13)B. Facility policy and procedureThe Food Preparation and Service policy, revised November 2022, was provided by the NHA on 4/9/26 at 4:33 p.m. It revealed in pertinent part, Foods are not thawed at room temperature. Appropriate thawing procedures include thawing in the refrigerator in a drip-proof container, completely submerging the item in cold running water (70 degrees Fahrenheit or below), thawing in a microwave oven and then cooking and serving immediately, or thawing as part of a continuous cooking process.C. ObservationsOn 4/6/26 at 9:10 a.m. frozen American goulash was in a container and placed inside the convection steamer with the door open, and the steamer was not turned on. The outside of the metal pan had a visible layer of white frost and ice buildup. D. Staff interviewsCK #2 was interviewed on 4/6/26 at 9:18 a.m. CK #2 said the goulash was frozen and he put it in the steamer to prepare it for that day's lunch.The DM was interviewed on 4/8/26 at 2:45 p.m. The DM said frozen food was pulled from the freezer three days in advance for meal preparation and placed in the refrigerator to thaw. The DM said meats were stored on the bottom rack of the upright cart in the refrigerator after they were pulled from the freezer. The DM said staff could use the steamer and microwave when thawing or reheating frozen food. The DM said the planned menu item for that day was herbed roasted chicken, however due to supply issues, the facility prepared goulash as a backup. The DM said she removed the pan of goulash from the freezer that morning at approximately 9:00 a.m. and handed it to CK #2. The DM said CK #2 should not have left the steamer door open and should have closed it and started cooking the goulash. The DM said she would have placed the goulash in the oven at 350 degrees Fahrenheit (F), and slowly cooked it until it reached an internal temperature of 165 degrees F. The DM said CK #2 used the steamer instead to keep the food moist. The DM said CK #2 had not been trained on proper thawing practices and said CK #2 was resistant to learning new skills but was a good CK. The DM said she had guided staff on proper handling of frozen food. The DM said dietary staff were trained annually and received monthly in-service education. The DM said proper thawing was important due to bacterial growth and the risk of residents becoming ill.CK #3 was interviewed on 4/8/26 at 3:57 p.m. CK #3 said to thaw frozen meat it was removed from the freezer, kept in its original packaging and placed in pans under cold running water. CK #3 said if the meat was frozen solid, he left it out in the open for a few hours and then placed it in the walk-in refrigerator. CK #3 said the next day he took it out and prepared it. CK #3 said he was trained in thawing through ServSafe and he had not received thawing training at the facility.CK #3 said for cooked goulash he reheated it in the oven at 350 degrees Fahrenheit (F) for about one hour until the internal temperature reached 165 to 170 degrees F. CK #3 said he only used the steamer for thin chicken breast for about 15 minutes before cooking it in the oven. CK #3 said he would not use the steamer for goulash because he was not trained to use that method and it was not appropriate for thawing and reheating that type of food. CK #3 said he used a thermometer to check food temperatures. CK #3 said if food was undercooked, he placed it back in the oven for about 15 minutes. CK #3 said if food was overcooked, he offered the resident an alternative.The RD was interviewed on 4/9/26 at 1:25 p.m. The RD said frozen food items should be placed in the refrigerator for 24 to 48 hours to thaw. The RD said the food could then be thawed under cool running water and reheated in the oven until it reached 165 degrees F. The RD said she inspected the kitchen monthly with the DM. The RD said they reviewed food temperatures, cleanliness, equipment function and tray accuracy. III. Hair netsA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 4/16/26. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (2-402.1)B. Facility policy and procedureThe Food Preparation and Service policy, revised November 2022, was provided by the NHA on 4/9/26 at 4:33 p.m. It revealed in pertinent part, Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint) so that hair does not contact food.C. ObservationsOn 4/7/26 at 2:18 p.m. five staff members were in the kitchen including the dietary manager (DM), cook (CK) #2, and three unknown dietary staff. The DM wore a hair net that covered only the upper portion of the hair and hair below the hair net remained uncovered. CK #2 wore a hat, and the other three staff members did not wear hair nets and their hair was exposed.On 4/8/26 at 8:41 a.m. dietary aide (DA) #2 was in the kitchen assisting with breakfast and did not have a hair net on and went to get one and put it on.D. Staff interviewsThe DM was interviewed on 4/8/26 at 2:45 p.m. The DM said staff were required to wear hair nets whenever they were in the kitchen. The DM said there was a sign outside the kitchen door that reminded them to wear it and hair nets are always available for staff.DA #1 was interviewed on 4/8/26 at 3:22 p.m. DA #1 said the facility required her to wear a hair net in the kitchen and when working with or preparing food. DA #1 said staff trained her to keep her hair back in a hair net. DA #1 said hair nets were used to keep food sanitary and prevent hair from getting into food. DA #1 said if someone forgot to wear a hair net they would be reminded to wear it. DA #1 said hair nets were available at all times.CK #3 was interviewed on 4/8/26 at 3:57 p.m. CK #3 said the facility required him to wear a hair net anytime he entered the kitchen. CK #3 said hair nets kept food sanitary and prevented hair from getting into food. CK #3 said when he first started working at the facility there were issues with hair in food, and staff trained employees to wear hair nets. CK #3 said if someone forgot to wear a hair net they would be reminded to wear it. CK #3 said hair nets were available at all times.The RD was interviewed on 4/9/26 at 1:25 p.m. The RD said she expected all employees to always wear a hair net in the kitchen. The RD said she ensured employees understood the importance of hair nets in preventing contamination through in-service training. IV. Kitchen equipment maintenanceA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations (revised 3/16/24), was retrieved on 12/22/25. It revealed in pertinent part, Materials that are used in the construction of utensils and food-contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be: finished to have a smooth, easily cleanable surface. Multiuse food contact surfaces shall be:smooth, free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections, free of sharp internal angles, corners and crevices, finished to have smooth welds and joints. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4)B. ObservationsOn 4/6/26 at 9:07 a.m. it was observed that the interior right side wall of the microwave had peeling paint that extended from the bottom to the top of the wall with bubbling present.On 4/8/26 at 3:25 p.m. the DM unplugged the microwave and said she would get another one.C. Staff interviewsThe DM was interviewed on 4/8/26 at 2:45 p.m. The DM said she would replace the microwave because she did not want bubbling paint to contaminate the food. The DM said they did not use that microwave that often and said another microwave was available and in fully operating condition. V. Maintain the kitchen in a sanitary conditionA. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, were retrieved on 4/16/26. It revealed in pertinent part, Food employees shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. (2-401.11)B. ObservationsOn 4/7/26 at 2:18 p.m. DA #1 sat at the food preparation table in the kitchen and ate lunch.C. Staff interviews The DM was interviewed on 4/8/26 at 11:53 a.m. The DM said when there was leftover food, staff received the food and ate at a designated area away from the kitchen. The DM said when the kitchen was busy, staff ate in the kitchen. The DM said DA #1 had just come on shift and was eating lunch at that time. The DM was interviewed again on 4/8/26 at 2:45 p.m. The DM said employees were not allowed to eat in the kitchen or in the food preparation areas and were expected to eat in the employee lounge. The DM said she monitored by being present in the kitchen throughout the day. The DM said eating in the kitchen could cause crumbs on hands or around the mouth and increased contamination risk. The DM said she spoke with DA #1 and provided education.The RD was interviewed on 4/9/26 at 1:25 p.m. The RD said she had seen staff eat in the kitchen and said this was not appropriate due to infection control concerns. The RD said when she observed staff eating in the kitchen, she told them the facility expectations to eat at a designated area. The RD said she would inform the DM when staff ate in the kitchen.

Based on observations, record review and interviews, the facility failed to ensure four (#5, #9, #47 and #61) of four residents out of 39 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure staff obtained a physician's order specifying personalized settings for air mattresses for Resident #5, Resident #9, Resident #47 and Resident #61; and, -Ensure staff maintained air mattresses according to the manufacturer's recommendations for Resident #5, Resident #9, Resident #47 and Resident #61.Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP), Prevention and Treatment of Pressure Ulcers and Injuries(3/17/26), retrieved on 4/16/26 from https://www.guidelinecentral.com/guideline/23835, It is good practice for organizations to maintain an inventory of, or access to, a range of full body support surfaces appropriate to the clinical context. The inventory should be maintained, stored and used in accordance with manufacturer recommendations. It is good practice to use a full body support surface or integrated bed system that appropriately accommodates the weight, height, size and body mass distribution of the individual. II. Facility policy and procedure The Use of Support Surfaces policy and procedure, revised 2024, was provided by the nursing home administrator (NHA) on 4/9/26 at 4:42 p.m. It read in pertinent part, Support surfaces will be utilized in accordance with manufacturer recommendations including considerations for contraindications. The director of nursing (DON) will maintain a list of support surfaces used in the facility, including product specifications. Arrangements will be made with rental vendors for obtaining this information. A schedule for inspection and replacement will be established accordingly. For powered devices, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and inflation.III. Manufacturer's instructions According to the Compass Healthcare's Meridian Medical Ultra-Care Series, user manual: pp 7-8, retrieved on 4/16/26 from https://compasshealthbrands.com/itemFiles/APM%20User%20Guide.pdf, Check to see if a suitable pressure is selected by sliding one hand between the air mattress and the foam base (or bed frame if there is no foam base) to feel the patient's buttocks. User should be able to feel the space in between and the acceptable range is approximately 25 to 40 millimeters (one inch to one and a half inches). The static mode provides a stable surface that makes it easier for the patient to transfer or reposition. IV. Resident #5A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included congestive heart failure (CHF), peripheral vascular disease and chronic respiratory failure with hypoxia. The 3/10/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident used a walker. She required supervision with eating, toileting and showering. She required set up assistance for oral hygiene and personal hygiene. B. Resident observation On 4/9/26 at 9:12 a.m. Resident #5's air mattress was observed. The air mattress was labeled Meridian Medical. The air mattress had a control panel which included an adjustable firmness dial located on the left side, labeled from soft to firm. There was a green switch labeled power and an orange switch labeled static. Both switches were illuminated. Above the power and static switches were two indicators labeled normal pressure and lower pressure. The normal pressure indicator was illuminated with a green light. The low pressure indicator was not illuminated. The adjustable firmness dial was set to the second blue block of the dial on the left side. C. Record Review Review of Resident #5's April 2026 CPO revealed the following physician's order: Apply an air mattress and check settings every shift for wound healing and prevention. Monitor settings, ordered 3/25/26.-However, the physician's order did not indicate what settings the mattress should be set on. The 3/23/26 nurse progress note revealed Resident #5 admitted to hospice care services with a diagnosis cerebrovascular disease with related diastolic CHF. An air mattress was provided by hospice and in place. -However a review of Resident #5's electronic medical record (EMR), including the hospice notes, did not reveal an assessment or documentation of what the air mattress settings should be for Resident #5.-There was no documentation in the resident's EMR to indicate the resident's mattress was being monitored and maintained on a routine basis. V. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia, type 2 diabetes mellitus, emphysema, stage 4 chronic kidney disease and pressure ulcer of the sacral region.The 1/19/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident used a wheelchair. He required setup assistance with eating. He required partial assistance with oral hygiene and substantial assistance with toileting and personal hygiene. B. Observation On 4/8/26 at 12:04 p.m. Resident #9's air mattress was observed. The air mattress was labeled Meridian Medical. The air mattress had a control panel which included an adjustable firmness dial located on the left side, labeled from soft to firm. There was a green switch labeled power and an orange switch labeled static. Both switches were illuminated. Above the power and static switches were two indicators labeled normal pressure and lower pressure. The normal pressure indicator was illuminated with a green light. The low pressure indicator was not illuminated. The adjustable firmness dial was set to the middle of the dial. C. Record review Review of Resident #9's April 2026 CPO revealed the following physician's order: Apply an air mattress and check settings every shift for wound healing and prevention. Monitor settings, ordered 12/25/25.-However, the physician's order did not indicate what settings the mattress should be set on. The skin care plan, initiated 12/1/25 and revised 2/12/26, revealed Resident #9 was at risk for skin breakdown due to incontinence, decreased mobility, and terminal diagnosis with end of life focus. Interventions included applying an air mattress and checking settings.-However, the care plan did not indicate what settings the air mattress should be set on. -A review of Resident #9's EMR, including hospice notes, did not reveal an assessment and documentation of what the air mattress settings should be for Resident #9.-There was no documentation in the resident's EMR to indicate the resident's mattress was being monitored and maintained on a routine basis. VI. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included hypertensive heart disease, atherosclerotic heart disease, senile degeneration of the brain, restlessness and agitation. The 3/6/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. She used a wheelchair. She required partial assistance with eating and required substantial assistance with personal hygiene. She was dependent on oral hygiene, toileting, and showering, B. Observation On 4/8/26 at 12:01 p.m. Resident #47's air mattress was observed. The air mattress was labeled Meridian Medical. The air mattress had a control panel which included an adjustable firmness dial located on the left side, labeled from soft to firm. There was a green switch labeled power and an orange switch labeled static. Both switches were illuminated. Above the power and static switches were two indicators labeled normal pressure and lower pressure. The normal pressure indicator was illuminated with a green light. The low pressure indicator was not illuminated. The adjustable firmness dial was set to the fifth blue block on the left side of the dial. C. Record Review Review of Resident #47's April 2026 CPO revealed the following physician's order: Apply an air mattress and check settings every shift for wound healing and prevention. Monitor settings, ordered 2/20/26.-However, the physician's order did not indicate what settings the mattress should be set on. -A review of Resident #47's EMR, including hospice notes, did not reveal an assessment and documentation of what the air mattress settings should be for Resident #47.-There was no documentation in the resident's EMR to indicate the resident's mattress was being monitored and maintained on a routine basis. VII. Resident #61 A. Resident status Resident #61, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included dementia, spinal stenosis (narrowing of the spinal canal that caused pressure on the spinal cord and nerves), peripheral vascular disease (slow progressive circulation disorder involving narrowed or blocked vessels) and pressure-induced deep tissue damage of right heel. The 2/27/26 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of seven out of 15. The resident used a wheelchair. He required partial supervision with eating. He was dependent on oral hygiene and toileting. B. ObservationOn Resident #61's air mattress setting was observed. The brand was Genesis III, The control panel included an adjustable firmness dial located on the left side, labeled from softer to firmer, with weight indicators ranging from 75 pounds (lbs) to 500 lbs. 75 lbs was on the soft setting and 500 lbs was on the firmer setting. The firmness dial on Resident #61's was set near the 225 lb setting. The power indicator and the lower pressure indicator lights were on. The normal pressure indicator light was not on. -However, record review revealed Resident #61 weighed 180 lbs, indicating the air mattress was not at the correct setting. C. Record review Review of Resident #61's April 2026 CPO revealed the following physician's order: The 9/25/26 behavior note revealed an air mattress was present on Resident #61's bed.Apply an air mattress and check settings every shift for wound healing and prevention. Apply an air mattress as indicated for wound healing and prevention. Monitor settings. Ordered 10/9/25. -However, the physician's order did not indicate what settings the mattress should be set on.-A review of Resident #61's EMR did not reveal an assessment and documentation of what the air mattress settings should be for Resident #61.-There was no documentation in the resident's EMR to indicate the resident's mattress was being monitored and maintained on a routine basis. VIII. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/9/26 at 9:46 a.m. LPN #1 said nurses were responsible for checking residents' air mattress settings. She said she knew to check based on a physician's order. LPN #1 said when a resident first had an air mattress delivered, the durable medical equipment (DME) company set up the air mattress according to the hospice care service company's order. She said the hospice care services company was responsible for routine maintenance and taking care of any issues with the mattress. She said she knew a resident's mattress was set on the right setting by touching the mattress and making sure the mattress did not touch the bed frame. She said residents had air mattresses for comfort and for residents who had wounds or did not eat well. LPN #1 said she was familiar with Resident #5, Resident #9, Resident #47 and Resident #61. She said the residents' air mattress settings were based on her touching their mattress and making sure the mattress did not touch the bed frame. The DON was interviewed on 4/9/26 at 12:49 p.m. The DON said nurses were responsible for checking residents' air mattress settings. She said the nurses knew they should check the settings because there was a physician's order to check the mattress every shift. The DON said nurses knew the air mattress settings based on the resident's weight. The DON said not every air mattress they had in the facility had settings based on weight. She said the settings for the other air mattresses should be based on the manufacturer's recommendations. The DON said she asked the hospice care services company for the manufacturer's manual for the air mattress that was not based on residents' weights, but she was unable to receive a copy of the manual. The DON said nurses checked the air mattress settings based on feel and they should make sure they did not feel the bar of the resident's bed frame. The DON said the DME company would come out to fix air mattresses as needed but they did not perform general maintenance of the air mattresses. The DON said residents had an air mattress for comfort, to prevent skin breakdown and for residents who were compromised. The DON said she was familiar with Resident #5, Resident #9, Resident #47 and Resident #61. She said the residents' air mattress settings were based on the nurses' touch to the residents' air mattresses during their shifts. -However, Resident #61's air mattress indicated the settings should be based on the resident's weight (see above)

Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for three (#57, #52 and #5) of five residents reviewed for oxygen services out of 39 sample residents. Specifically, the facility failed to:-Ensure there was a physician's order in place for Resident #57's continuous positive airway pressure (CPAP) machine and routine maintenance of the CPAP; and,-Ensure there were appropriate oxygen orders in place for Resident #52 and Resident #5.Findings include: I. Professional reference According to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 4/14/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) Devices such as high flow oxymasks, CPAP, BiPAP (bilevel positive airway pressure), or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. (Chapter 11) Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment. II. Facility policy and procedure The Oxygen Administration policy, dated 2025, was provided by the nursing home administrator (NHA) on 4/9/26 at 1:00 p.m. It read in pertinent part: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia (low levels of oxygen in the body's tissues). Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. Personnel authorized to initiate oxygen therapy include physicians, registered nurses (RN), licensed practical nurses (LPN) and respiratory therapists. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: -The type of oxygen delivery system; -When to administer, such as continuous or intermittent and/or when to discontinue; and, -Equipment setting for the prescribed flow rates. Staff shall perform hand hygiene and don (put on) gloves when administering oxygen or when in contact with oxygen equipment. Other infection control measures include: -Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated; -Keep delivery devices covered in plastic bag when not in use; -Cleaning and care of equipment shall be in accordance with facility policies for such equipment; and, -The equipment needed for oxygen administration will depend on the type of delivery system ordered. Types of delivery systems include: Nasal Cannula – Oxygen is administered through plastic cannulas in the nostrils. Effective for low oxygen concentrations less than 40%. Requires humidification at flow rates greater than 4 liters per minute (LPM). CPAP Mask – This mask is part of a system that allows a resident to receive continuous positive airway pressure (CPAP), with or without an artificial airway. The system is comprised of a mask, tubing, and a machine that generates a constant flow of air pressure. Machines have different settings. III. Resident #57 A. Resident status Resident #57, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included obstructive sleep apnea. The 3/20/26 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He used a walker and wheelchair for mobility. He had no impairment of upper or lower extremities and was independent with activities of daily living (ADL). The MDS assessment did not indicate the resident used a CPAP. B. Observations and resident interview On 4/6/26 at 3:29 p.m. Resident #57 said he wore a CPAP at night. He said the staff did not clean it, but they brought water for it. The mask was observed on top of the bedside table next to the CPAP machine and was not contained in a storage bag. On 4/7/26 at 12:30 p.m. the CPAP mask was observed on the bedside table next to the machine, lying on top of a lamp base and was not contained in a storage bag. On 4/8/26 at 9:30 a.m. the CPAP mask was on the bedside table next to the machine, lying on top of a lamp base and was not contained in a storage bag. On 4/9/26 at 10:00 a.m. the CPAP mask was on the bedside table next to the machine, lying on top of a lamp base and was not contained in a storage bag. Cross-reference F880 for failure to maintain appropriate infection prevention and control. C. Record review A review of Resident #57's April 2026 CPO revealed no physician's orders for the CPAP machine or instructions for maintenance and cleaning of the equipment. The respiratory/oxygen care plan, initiated 3/17/26, indicated Resident #57 was at risk for complications related to a compromised respiratory system related to obstructive sleep apnea (OSA). Interventions included administering oxygen as ordered, administering medications as ordered, educating the resident to use breathing techniques: purse lips, cough and deep breathing and notifying the physician of increased complaints of difficulty in breathing. -The care plan did not include the use of the CPAP machine or the cleaning/maintenance of the equipment. Review of the 3/13/26 hospital note indicated Resident #57 had OSA and the resident was to continue use of the CPAP machine at night, per his home settings. D. Oxygen representative interview The oxygen company's representative was interviewed on 4/9/26 at 9:18 a.m. The oxygen company's representative said when a resident was on oxygen their company provided routine visits to change tubing and cannulas and they also provided the bags to store the cannula/mask in if the resident was not wearing the oxygen. He said if a resident brought a CPAP from home he would check in with them to see if any equipment was needed. He said he was not notified by the facility that Resident #57 had a CPAP. E. Staff interview The director of nursing (DON) was interviewed on 4/9/26 at 9:26 a.m. The DON said she did not know Resident #57 had a CPAP machine when he was admitted to the facility. She said when a resident had a CPAP machine brought from home, physician's orders for the CPAP machine and routine cleaning/maintenance of the equipment were to be entered into the resident's electronic medical record (EMR) and the care plan would be updated as well. She said the physician's orders for Resident #57's CPAP machine were missed being added to the resident's EMR on his admission to the facility. F. Facility follow-up On 4/9/26 at 9:47 a.m. a review of Resident #57's April 2026 CPO revealed the DON had entered the following physician's orders related to the resident's CPAP machine: Humidifier cleaning: Cleaning to be done weekly. Cleanse the humidifier with warm soapy water, rinse thoroughly and dry with a clean cloth or allow to air dry. One time a day every Monday for CPAP maintenance, ordered 4/9/26. Humidifier water: Empty the distilled water each morning from the CPAP machine. After cleaning, refill with distilled water. One time a day for CPAP maintenance, ordered 4/9/26. Mask/nasal pillow cleaning: Masks and nasal pillows must be cleaned in the morning. Clean CPAP using warm water and a cloth daily. One time a day, ordered 4/9/26. Tube cleaning: Clean tube with mild detergent that is not anti-bacterial in warm water. Dry the interior of the hose, connect it to the CPAP machine and allow it to run for approximately 15 minutes or until moisture has evaporated. One time a day every Monday for CPAP maintenance, ordered 4/9/26. Additionally, the resident's care plan was updated as follows: Apply CPAP as ordered. Ensure settings are as physician ordered, initiated 4/9/26. -However, the physician's orders for the CPAP machine and the care plan for the CPAP machine were not entered into Resident #57's EMR until the concern was brought to the facility's attention during the survey. IV. Resident #52 A. Resident status Resident #52, age less than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included chronic respiratory failure with hypoxia. The 3/25/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. She used a walker and wheelchair for mobility. She had impairment of one lower extremity and required partial to moderate assistance with ADLs. The assessment indicated the resident required oxygen therapy. B. Observations and resident interview Resident #52 was interviewed on 4/6/26 at 3:39 p.m. Resident #52 said she always wore oxygen and it should be set at a flow rate of 2 LPM. Observation of the resident's oxygen concentrator revealed it was set at a flow rate of 2 LPM. On 4/7/26 at 10:00 a.m. the resident's oxygen concentrator was set at a flow rate of 2 LPM. On 4/8/26 at 9:00 a.m. the resident's oxygen concentrator was set at a flow rate of 2 LPM. C. Record review Review of Resident #52's April 2026 CPO revealed the following physician's order: The respiratory/oxygen care plan, initiated 3/17/26, revealed Resident #52 was at risk for complications related to a compromised respiratory system related to chronic respiratory failure. Interventions included administering oxygen as ordered, administering medications as ordered, educating the resident to use breathing techniques: purse lips, cough and deep breathing and notifying the physician of increased complaints of difficulty in breathing. Oxygen via nasal cannula, titrate to 90% continuously, ordered 3/10/26. -However, the physician's order did not indicate a flow rate that the oxygen was to be set on. The 3/10/26 hospital note revealed Resident #52 had chronic hypoxic respiratory failure and was on oxygen at 2 LPM per nasal cannula at baseline. D. Staff interviews LPN #4 was interviewed on 4/9/26 at 9:00 a.m. LPN #4 said Resident #52's oxygen order did not indicate a continuous LPM flow rate and she would not know what the oxygen was supposed to be set on when the order read that way. She said if a resident's oxygen saturation level (measure of oxygen in the blood) were to drop below 90%, she would notify the physician for further orders. The DON was interviewed on 4/9/26 at 9:41 a.m. The DON said Resident #52's oxygen order was an incorrect order. She said the facility did not use titration orders and nursing was to use the facility's oxygen template. She said upon the resident's admission to the facility, the nurse did not enter the correct physician's order for oxygen into the resident's EMR. E. Facility follow-up On 4/9/26 at 9:42 a.m. the DON entered the following physician's order related to oxygen into Resident #52's April 2026 CPO: Oxygen 2 LPM via nasal cannula to keep saturations greater than (>)89% continuously, ordered 4/9/26. -However, the physician's order for Resident #52's oxygen flow rate was not updated until the concern was brought to the facility's attention during the survey. V. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included congestive heart failure (CHF), peripheral vascular disease and chronic respiratory failure with hypoxia. The 3/10/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The resident used a walker. She required supervision with eating, toileting and showering. She required set up assistance for oral hygiene and personal hygiene. The MDS assessment indicated Resident #5 was not receiving oxygen therapy. B. Resident interview and observations Resident #5 was interviewed on 4/7/26 at 9:38 a.m. Resident #5 was sitting on the side of the bed and did not have an oxygen nasal cannula in her nose. An oxygen concentrator was observed next to the wall where the resident's bathroom was located. Resident #5 said she did not know why the oxygen concentrator was there because she did not use oxygen. Resident #5 was observed on 4/7/26 from 12:05 p.m. to 1:07 p.m in the dining room. She was not receiving oxygen. Resident #5's room was observed on 4/9/26 at 9:12 a.m. An oxygen concentrator was observed to still be next to the wall where the resident's bathroom was located. C. Resident's representative interview Resident #5's representative was interviewed on 4/8/26 at 9:18 a.m. The resident's representative said she was a nurse and Resident #5 had a physician's order for oxygen as needed. The resident's representative said the order was as needed because when she had visited Resident #5, the resident looked like her oxygen was low. The resident's representative said she had asked the facility staff to take the resident's vital signs and her oxygen saturation level was low. She said when Resident #5's oxygen saturation level was low, the facility used the oxygen concentrator. D. Record review A review of Resident #5's April 2026 CPO revealed the following physician's orders: Oxygen via nasal cannula at 2 LPM to 3 LPM continuously to maintain oxygen saturation greater than 89%, ordered on 3/9/26 and discontinued on 4/9/26 (during the survey). May take oxygen off for short intermittent times to refill portable oxygen tanks, ordered on 3/9/26. -However, observations revealed Resident #5's oxygen was not being administered continuously, per physician's orders. Head of bed elevated, resident is unable to lay flat due to shortness of breath, ordered 3/9/26. The respiratory and oxygen care plan, initiated 6/11/25 and revised 4/9/26, revealed Resident #5 was at risk for complications due to a compromised respiratory system related to chronic respiratory failure with hypoxia. Interventions included administering medications as ordered, administering oxygen as ordered, educating the resident to use breathing techniques, elevating the head of the bed due to shortness of breath, encouraging the resident to be out of bed as tolerated and monitoring vital signs as ordered. E. Staff interviews LPN #1 was interviewed on 4/9/26 at 9:46 a.m. LPN #1 said nursing staff was responsible for ensuring residents had oxygen per the physician's orders. She said she was familiar with Resident #5. She said the resident had oxygen in case she needed it as a comfort measure. She said the physician's order in the resident's EMR said 2 LPM continuously, but it should read 2 LPM as needed. She said she would change the physician's to reflect Resident #5's actual oxygen needs. The DON was interviewed on 4/9/26 at 12:49 p.m. The DON said nursing staff was responsible for ensuring residents had oxygen per the physician's orders. She said she was familiar with Resident #5. She said Resident #5 had oxygen off and on due to her CHF. The DON said the resident had retained a lot of fluid at one point and required oxygen continuously. The DON said Resident #5's representative wanted her to have oxygen available as needed. The DON said the resident sometimes used oxygen at night. She said if Resident #5 was using oxygen as needed, the physician's order should reflect that. The DON looked at Resident #5's April 2026 CPO during the interview and said it was as needed and said the order was changed today, 4/9/26. The DON said she did not know it had changed after LPN #1 realized the order was incorrect. F. Facility follow-up On 4/9/26 at 12:07 p.m. the following physician's order related to oxygen was entered into Resident #5's April 2026 CPO: Oxygen via nasal cannula at 2 LPM to 3 LPM as needed to maintain oxygen saturation greater than 89%. -However, the physician's order for Resident #5's oxygen was not updated to oxygen as needed until the concern was brought to the facility's attention during the survey.

Based on observations and interviews, the facility failed to provide proper storage for medications for four of five medication carts and one of three medication storage rooms. Specifically, the facility failed to:-Ensure eye drops, inhalers and Tuberculin Purified Protein Derivative (PPD) vials were labeled with the date they were opened;-Ensure glucometer test strips and glucose control solutions were labeled with the date they were opened; and,-Ensure glucometer test strips and glucose control solutions were discarded when expired.Findings include:I. Professional referenceAccording to the manufacturer Catalent Pharma Solutions Xalatan(R) latanoprost ophthalmic solution package insert, , revised [DATE], and retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf,Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees Celsius (77 degrees Fahrenheit - F) for six weeks.According to the manufacturer, GlaxoSmithKline Highlights of Prescribing Information, 2017, accessed on [DATE], from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/209482s016lbl.pdf, Discard Trelegy Ellipta (inhaler) six weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. According to the manufacturer, [NAME] True Metrix Control Solution, [DATE], accessed on [DATE] fromhttps://imgcdn.[NAME].com/CumulusWeb/Click_and_learn/truemetrix_control_solution_ifu_2015-03.pdf, Write date first opened on bottle. Discard bottle after expiration date printed on the bottle label or three months after the date written on the bottle, whichever comes first.According to the manufacturer, [NAME] Professional Monitoring Blood Glucose Test Strips, date not available, accessed on [DATE] fromhttps://imgcdn.[NAME].com/CumulusWeb/Click_and_learn/truemetrixpro_test_strips_ifu_960297_and_960298.pdf, Write the date opened on the test strip vial label when removing the first test strip. Discard all unused test strips in the vial after either the date printed on the test strip vial label or four months after the date opened, whichever comes first.According to the manufacturer, JHP Pharmaceuticals Aplisol Tuberculin Purified Protein Derivative, Diluted, accessed on [DATE] from https://www.fda.gov/media/74862/download?attachment, Vials in use more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.II. Facility policy and procedureThe Medication Storage policy, dated 2025, was provided by the nursing home administrator (NHA) on [DATE] at 4:42 p.m. p.m. It read in pertinent part, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.III. Observations and interviewsOn [DATE] at 3:24 p.m. the Sunlight Hall medication cart was observed with licensed practical nurse (LPN) #1. The following was observed:One opened bottle of Xalatan eye drops for Resident #61 with no open date.One opened Trellegy inhaler for Resident #56 with no open date. LPN #1 said the inhaler could be used until the medication was complete. LPN #1 said she used to write open dates on all of the medications, but she was told it was not necessary anymore. Two opened bottles of blood glucose test strips without open dates. LPN #1 said the test strips were good until the expiration date on the bottle.On [DATE] at 3:39 p.m. the Sunlight Hall medication storage room was observed with LPN #1. The following was observed:One opened level one glucose monitoring control solution and one opened level two glucose monitoring control solution with open dates that read [DATE]. LPN #1 said the control solution was good until the expiration date on the bottle.One opened Tuberculin PPD 5 TU (tuberculin units) per 0.1 milliliter (ml) vial without an open date. LPN #1 said the vial was good until the expiration date, or until the medication was completed, whichever came first. On [DATE] at 3:53 p.m. the Frontier unit medication cart B was observed with RN #1. The following was observed:One opened container of glucose test strips was not labeled with the date opened. RN #1 said the test strips were good until the expiration date on the container.On [DATE] at 3:59 p.m. the Frontier unit medication cart A was observed with RN #2. The following was observed:Two opened containers of glucose test strips were not labeled with the date opened. On [DATE] at 4:28 p.m. the Red Cloud unit medication cart was observed with LPN #2. The following was observed:Three opened containers of glucose test strips, one container each for Resident #78, Resident #66 and Resident #40, not labeled with the date opened.On [DATE] at 11:23 a.m. the Frontier nurses' station was observed with RN #2. The following was observed:One opened level one glucose control monitoring solution without an open date. RN #2 said the solution should be labeled with an open date.On [DATE] at 11:58 a.m. the shared nurses' station for the Red Cloud unit and the Castle Peak unit was observed with LPN #1. The following was observed:Two opened containers of glucose test strips not labeled with the date opened. IV. Additional staff interviewThe director of nursing (DON) was interviewed on [DATE] at 1:02 p.m. The DON said there was a misunderstanding among the nursing staff about what medications needed to be labeled with an open date. The DON said the facility used to label every medication with an open date until their pharmacy representative said they did not need to date over-the-counter medications. The DON said patient-specific medications and glucometer supplies still needed to be labeled. The DON said the glucose test strips were good for 30 days after opening and the glucose monitoring control solutions were good for 90 days after opening. She said both would be ineffective if used past their expiration dates. The DON said the Tuberculin PPD should have an open date on it, because using it past its expiration date could result in a false test result. The DON said the Trellegy inhaler was only good for about 30 days and would be ineffective if used after its expiration date.

Based on observations and interviews, the facility failed to maintain infection control procedures designed to provide a safe and sanitary environment to prevent the development and transmission of diseases on three of four units and in one of two dining rooms.Specifically, the facility failed to:-Ensure staff wore the appropriate personal protective equipment (PPE) while providing care to -Resident #59, who was on enhanced barrier precautions (EBP);-Ensure staff offered residents hand hygiene before meals; and,-Ensure oxygen cannulas and CPAP (continuous positive airway pressure - a machine used to treat breathing issues while sleeping) masks were stored in a sanitary manner.Findings include: I. Failed to ensure staff wore the appropriate PPE while providing care to Resident #59, who was on EBP A. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), (4/2/24), retrieved on 4/13/26, from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP may be indicated for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, and infection or colonization with an MDRO. B. Facility policy and procedure The Enhanced Barrier Precautions policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/9/26 at 4:42 p.m. It read in pertinent part, Enhanced barrier precautions (EBP) are used as an infection prevention and control intervention to reduce the spread of multidrug-resistant organisms (MDRO) to residents. EBP employs targeted gown and glove use during high-contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP include: dressing; bathing/showering; transferring; providing hygiene; changing linens; changing briefs or assisting with toileting; device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator); and wound care (any skin opening requiring a dressing). C. Observations and staff interview On 4/8/26 at 3:47 p.m. a sign posted on Resident #59's door indicated she was on EBP. The resident had an indwelling urinary catheter. Certified nurse aide (CNA) #8 was observed transferring Resident #59 from her wheelchair to her bed, using a hands-on slide board transfer method. CNA #8 reached for a PPE gown and Resident #59 told CNA #8 she did not need a gown because the gowns were only for infections like influenza, and staff did not wear the gowns for her care. CNA #8 shrugged, donned (put on) gloves and continued with the resident's care without putting on a gown. -CNA #8 failed to don the appropriate PPE for high-contact resident care. On 4/8/26 at 4:49 p.m. registered nurse (RN) #1 was observed in Resident #59's room performing urinary catheter care. RN #1 donned gloves, disconnected the catheter bag from the tubing, and connected a syringe to the tubing. RN #1 pressed the catheter bag tubing between her knee and the bed, which kept the tip of the tubing suspended in the air. RN #1 irrigated the catheter with a medicated solution, then reconnected the tubing. After the care was completed, RN #1 said she was not sure where to place the catheter bag tubing during the procedure, so she used her knee to keep the tubing from touching the bed. RN #1 said she should have worn a gown to irrigate the resident's urinary catheter, but she had forgotten to do so because she did not usually work with Resident #59. II. Failed to ensure staff offered residents hand hygiene before meals A. Professional reference According to the CDC's, Hand Hygiene For Patients, (2/27/24), retrieved on 4/14/26 from https://www.cdc.gov/clean-hands/about/hand-hygiene-for-healthcare.html?utm_source=chatgpt.com, Patients and visitors should clean their hands before preparing or eating food, before touching your eyes, nose, or mouth, after using the restroom, after blowing your nose, coughing or sneezing, after touching hospital surfaces. B. Observations During a continuous observation on the Castle Peak unit on 4/6/26, beginning at 12:35 p.m. and ending at 12:48 p.m., the following was observed: A meal tray cart was observed in the hall of the Castle Peak unit with residents' meal trays. There was no hand sanitizer or hand wipes observed on the cart. An unidentified staff member was delivering meal trays to residents' rooms and did not offer hand hygiene to residents. On 4/6/26 at 12:26 p.m. a room tray was delivered to room [ROOM NUMBER] by an unidentified CNA. The unidentified CNA did not offer the resident in room [ROOM NUMBER] hand hygiene prior to the resident eating. During a continuous observation on the Red Cloud unit on 4/6/26, beginning at 12:29 p.m. and ending at 12:40 p.m. CNA #1 was observed delivering meal trays to the residents. The meal trays were on a two-shelf cart. There were no hand wipes observed on the cart. CNA #1 went into room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] with the resident's meal trays. -However, CNA #1 failed to offer hand hygiene to the residents in the rooms prior to the meal being served. On 4/6/26 at 12:45 p.m. the main dining room was observed. There were no hand wipes or hand sanitizer observed on any dining tables. During a continuous observation of the main dining room on 4/7/26, beginning at 12:05 p.m and ending at 1:07 p.m., the following was observed: Staff were delivering lunch meals to residents seated at the tables. Resident #59 self-propelled a manual wheelchair into the dining room, and sat in front of a table. Resident #59 was not offered hand hygiene before being served her lunch. Resident #5, Resident #61 and Resident #47 were observed at a table for residents who needed feeding assistance. None of the residents were offered hand hygiene prior to being served their lunch. C. Resident interviews Resident #4 was interviewed on 4/7/26 at 12:30 p.m. Resident #4 said when meal trays were delivered to the rooms, hand hygiene was not offered to the residents, but would be appreciated. Resident #31 was interviewed on 4/7/26 at 12:39 p.m. Resident #31 said when meal trays were delivered to the rooms, staff did not offer hand hygiene, just the paper napkin that the silverware was wrapped in. Resident #30 was interviewed on 4/7/26 at 12:41 pm. Resident #30 said when meal trays were delivered to the rooms, staff did not offer hand hygiene. Resident #30 said residents got nothing to clean their hands other than the paper napkin on the tray. III. Failed to ensure oxygen cannulas and CPAP masks were stored in a sanitary manner A. Observations On 4/6/26 at 3:29 p.m. Resident #57's CPAP mask was observed lying on the bedside table next to the machine and on top of a lamp base. The CPAP mask was not contained in a storage bag. At 3:56 p.m. an oxygen concentrator was observed sitting by the window in room [ROOM NUMBER]. The oxygen concentrator was not running and had oxygen tubing and a nasal cannula attached. The oxygen tubing and nasal cannula were lying coiled on the floor and not contained in a storage bag. On 4/7/26 at 8:28 a.m. the oxygen concentrator in room [ROOM NUMBER] was not running and the tubing and nasal cannula were coiled and lying underneath the handle of the concentrator. There was no storage bag for the oxygen tubing and nasal cannula when not in use. At 12:30 p.m. Resident #57's CPAP mask was lying on the bedside table next to the machine on top of a lamp base and was not contained in a storage bag. On 4/8/26 at 9:12 a.m. the oxygen concentrator in room [ROOM NUMBER] was not running and the tubing and nasal cannula were coiled and lying underneath the handle of the concentrator. There was no storage bag for the oxygen tubing and nasal cannula when not in use. -At 9:30 a.m. Resident 57's CPAP mask was lying on the bedside table next to the machine on top of a lamp base and was not contained in a storage bag. On 4/9/26 at 10:00 a.m. Resident #57's CPAP mask was lying on the bedside table next to the machine on top of a lamp base and not contained in a storage bag. B. Resident interview Resident #57 was interviewed on 4/6/26 at 3:29 p.m. Resident #57 said he wore a CPAP at night and the staff did not clean it. He said staff had not provided a way to store the mask when it was not being used. C. Oxygen representative interview The oxygen representative was interviewed on 4/9/26 at 9:18 a.m. The oxygen representative said when a resident was on oxygen, their oxygen company provided routine visits to change oxygen tubing and nasal cannulas. The oxygen representative said the oxygen company also provided the bags to store CPAP masks and the oxygen tubing and nasal cannulas if the resident was not wearing the oxygen. He said the facility must notify the company when a resident had an oxygen order so appropriate supplies could be provided. He said he did not know that Resident #57 had a CPAP. D. Staff interview CNA #6 was interviewed on 4/9/26 at 9:56 a.m. CNA #6 said she knew Resident #57 used a CPAP but she did not know oxygen cannulas or CPAP masks needed to be stored in a bag when not in use to prevent cross contamination. IV. Additional staff interviews The infection preventionist (IP) and the director of nursing (DON) were interviewed together on 4/9/26 at 10:00 a.m. The IP said if a resident was on EBP and staff were transferring the resident with a slide board or providing urinary catheter care, the staff should wear PPE, which included gloves and gowns. The DON said if a resident was on EBP, staff should wear a gown and gloves for performing activities, such as slide-board transfers or urinary catheter care. The IP said staff should encourage and help residents to sanitize their hands at meal times. The DON said staff were expected to offer hand hygiene to residents prior to eating in the dining rooms and when room trays were delivered. The DON said oxygen nasal cannulas were to be stored in a plastic bag when the resident was not wearing the oxygen and the oxygen tubing and nasal cannula were not to be lying on the floor or stored under the handle of the oxygen concentrator because that could cause cross contamination. She said CPAP masks were to be cleaned routinely and stored in a plastic bag when not in use to prevent cross contamination.

Based on observations, interviews, and record review, the facility failed to provide adequate positioning and contracture management for residents to maintain their highest practicable level of functioning for two (#59 and #15) of three residents out of 39 sample residents.Specifically, the facility failed to: -Ensure staff were appropriately monitoring the use of a resistance band that was requested by Resident #59 to keep her left leg safely positioned on her wheelchair leg rest; and,-Ensure hand splints were provided in a timely manner for Resident #15, who had Swan neck deformities (a condition causing the middle knuckles of the hand to bend inward and the end knuckles to bend outward, creating an S-shape) in both hands.Findings include:I. Facility policy and procedureThe Resident Mobility and Range of Motion policy, revised July 2017, was provided by the nursing home administrator (NHA) on 4/9/26 at 4:42 p.m. It read in pertinent part, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with a limited range of motion will receive treatment and services to increase and/or prevent further decrease in ROM. Residents with limited mobility will receive appropriate services, equipment, and assistance to maintain mobility unless a reduction in mobility is unavoidable. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: pain, skin integrity issues, muscle wasting and atrophy, gait and balance issues that may lead to falls or fractures, contractures or other complications that could cause or contribute to immobility, impaired ROM or injury from falls. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.II. Failed to ensure staff were appropriately monitoring the use of a resistance band that was requested by Resident #59 to keep her left leg safely positioned on her wheelchair leg [NAME]. Resident statusResident #59, age less than 65, was admitted on [DATE]. According to the April 2026 computerized physician's orders (CPO), diagnoses included spastic hemiplegia affecting the left side, multiple sclerosis, lesion of the left upper limb ulnar nerve (impairment to a nerve in her arm), gait and mobility impairment, spinal stenosis, and flexion deformity of the left and right ankle and toes.The 3/18/26 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. Resident #59 used a wheelchair for mobility and was dependent on staff assistance for showers and transfers in and out of her wheelchair. Resident #59 had range of motion impairments to one upper extremity and both lower extremities. The MDS assessment documented Resident #59 needed substantial assistance with lower-body dressing.B. Resident observations and interviewsOn 4/6/26 at 12:23 p.m. Resident #59 was in her room, sitting in her manual wheelchair. Resident #59's left leg was tied to her wheelchair leg rest with a bright orange exercise resistance band around her calf. Resident #59 said she had a contracture of her left leg, which prevented her from bending her knee and caused the leg to point inward toward the midline of her body. Resident #59 said she used the resistance band because her left leg extended past her wheelchair leg rest and the resistance band was necessary to prevent her left leg from getting caught in the middle of the leg rests. Resident #59 said the facility did not have the right assistive devices for her.On 4/8/26 at 10:33 a.m. Resident #59 was observed with her left calf tied to her manual wheelchair. Resident #59 said she preferred the resistance band because she could hardly feel it on her leg and the assistive devices that physical therapy provided her were too bulky, which prevented her from getting her wheelchair under the dining room tables.On 4/8/26 at 3:47 p.m. Resident #59 was sitting in her wheelchair in the doorway to her room. Resident #59's left leg was tied to her wheelchair with the resistance band. Resident #59's feet touched the floor and she appeared to be sliding to the front of her wheelchair. Resident #59 said she was not able to position herself and she hoped staff would come help her reposition soon because she could not move independently in her current position.On 4/9/26 at approximately 4:15 p.m. Resident #59 was in her room, sitting in her wheelchair with the resistance band tied around her left calf. Resident #59 attempted to take the resistance band off her leg, but she could not reach any part of the band. Resident #59 then attempted to pull her pant leg up to bring the band closer to her hand. Resident #59 could not reach the band, and the band started to roll up. Resident #59 said she had a pair of scissors in her room, and if she needed to get the band off, she would have to find the scissors to cut the band off.C. Record review-Review of Resident #59's April 2026 CPO revealed no physician's orders to use a resistance band to assist Resident #59 in positioning her lower extremities. -The April 2026 CPO did not include physician's orders to monitor the use of the resistance band for skin breakdown or circulatory issues.The skin care plan, initiated 10/20/23, documented Resident #59 was at risk for skin breakdown.The activities of daily living (ADL) care plan, initiated 10/23/23 and revised 1/9/26, documented the use of a Velcro strap to keep Resident #59's left leg positioned properly to reduce the risk for injury. The care plan documented the resident could remove the Velcro strap without assistance, but indicated the resident refused to follow recommendations provided by therapy.-However, the care plan failed to document that the resident chose to use a resistance band to strap her leg to the chair instead of the Velcro strap.The assistive devices care plan, initiated 11/22/23, documented Resident #59 required assistive devices for mobility and positioning.The contracture care plan, initiated 4/25/25 and revised 1/2/26, revealed Resident #59 had a contracture related to a chronic disease process. Interventions included for Resident #59 to work with the therapy department for evaluation and treatment.-However, the care plan did not include the use of the resistance band for positioning Resident #59's leg.A nursing progress note, dated 6/2/25, documented Resident #59 used a resistance band to support her leg position on the foot rest. The physical therapy progress note, dated 10/8/25, documented Resident #59 reported using a resistance band to fixate her left leg onto her wheelchair pedal.The physical therapy recertification note, dated 1/18/26, documented Resident #59 had contractures at the hips, knees, and ankles. The note documented Resident #59 needed substantial assistance due to a high risk for injury to her left leg and decreased safety awareness. The note documented Resident #59 was provided with the proper positioning devices and modifications for positioning in her wheelchair.-Review of Resident #59's electronic medical record (EMR) failed to reveal documentation to indicate the following:-The medical condition the resistance band was being used to treat;-Identify who was allowed to apply the resistance band; -Where and how the resistance band was to be applied and used; -The type of specific direct monitoring and supervision provided during the use of the resistance band, including documentation of the monitoring; and,-The identification of how the resident's needs would be met during use of the resistance band, such as for re-positioning, meals, using the bathroom and hygiene. -Additionally, the resident's EMR failed to include documentation of the development and implementation of interventions to prevent and address any risks related to the use of the resistance band.The physical therapy progress note, dated 4/6/26, documented Resident #59 was educated on wheelchair positioning recommendations and the use of a wedge to position her legs instead of tying her leg to the leg rest. The note documented Resident #59 requested her leg be tied to the wheelchair at the end of the physical therapy session.D. Staff interviewsCertified nursing assistant (CNA) #5 was interviewed on 4/8/26 at 2:20 p.m. CNA #5 said Resident #59 usually had the CNAs tie her leg to the wheelchair with the resistance band. CNA #5 said she assumed physical therapy had approved the use of the resistance band for positioning because Resident #59 had been using it for positioning for the past few months. CNA #5 said Resident #59 needed help to get dressed and had diminished sensation in her legs.CNA #8 was interviewed on 4/8/26 at 2:41 p.m. CNA #8 said she was Resident #59's CNA. CNA #8 said the previous shift put the resistance band on Resident #59's leg and she did not know how long it had been on.Registered nurse (RN) #1 was interviewed on 4/8/26 at 3:55 p.m. RN #1 said she was Resident #59's nurse. RN #1 said she did not know Resident #59's leg was tied to her wheelchair. RN #1 said nurses should check residents' assistive devices at least once a shift for skin breakdown.The director of rehabilitation was interviewed on 4/9/26 at 12:43 p.m. The director of rehabilitation said she had recently learned Resident #59 had staff tie her leg to her wheelchair instead of using the wedge or Velcro strap provided by the physical therapy department. The director of rehabilitation said the use of the resistance band to align Resident #59's leg was okay if Resident #59 could remove the band herself and if it was not tied too tightly or left on for prolonged periods of time. The director of rehabilitation said if nursing staff applied the resistance band to Resident #59's leg, then nursing staff were also responsible for monitoring safety and performing skin checks. The director of rehabilitation said she was not aware Resident #59 could not remove the resistance band herself.The director of nursing (DON) was interviewed on 4/9/26 at 2:16 p.m. The DON said the therapy department managed all assistive devices, but nursing staff could apply, remove and monitor braces, splints, and other assistive devices with a physician's order. The DON said for residents with assistive devices, the nursing staff were expected to assess the resident at least twice a day for skin breakdown and circulation issues. The DON said if the equipment became ill-fitting or broke, nursing staff were expected to notify the rehabilitation department. The DON said she was aware Resident #59 used a resistance band to tie her leg to the leg rest of her wheelchair. The DON said she was told Resident #59 could remove the band herself and alternatives to the band had been offered. The DON said nursing staff should follow a physician's order to monitor Resident #59's skin and a care plan to use the resistance band for positioning. The DON said she did not see any current care plans or physicians' orders for the resistance band in Resident #59's EMR. The DON said she would add the resistance band to the resident's care plan and get the physician's orders to monitor Resident #59's use of the resistance band.III. Failed to ensure hand splints were provided in a timely manner for Resident #15, who had Swan neck deformities in both handsA. Professional ReferenceAccording to [NAME] and [NAME] C. [NAME], Managing Swan Neck and Boutonniere Deformities, copyright 2020, accessed on 4/16/26 from https://asht.org/sites/asht/files/images/International/Sept%202025/08%20Managing%20Swan%20Neck%20and%20Boutonniere%20Deformities%20Elzinga.pdf Swan neck and Boutonniere finger deformities result from extensor tendon imbalances. They can present acutely, most commonly in the setting of trauma (sharp laceration, blunt avulsion, burns) or as a progressive deformity. Corrective splinting is generally the first line of treatment of Swan neck and Boutonniere deformities of the fingers. Complete correction of Swan neck and Boutonniere deformities is difficult to achieve, but the function and esthetics of the interphalangeal joints of the fingers can be greatly improved with splinting and operative interventions. Swan neck deformities are first treated with splinting. Before any tendon rebalancing to correct a Swan neck or Boutonniere deformity, passive range of motion must be optimized. Hand therapy is important for all patients with these injuries. Corrective splinting, range of motion exercises, and education are essential elements of the patient's care. Early recognition and treatment of extensor tendon injuries is best to prevent extensor tendon imbalances and resultant swan neck and boutonniere deformities. Once established, these deformities can require prolonged courses of splinting and, less commonly, surgery for correction.B. Resident statusResident #15, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included type two diabetes, coronary heart disease, macular degeneration of the right eye, bipolar disorder and a history of falling.The 3/5/26 MDS assessment revealed the resident was cognitively intact, with a BIMS score of 15 out of 15. Resident #15 needed substantial assistance with his ADLs and needed set-up assistance with feeding. The MDS assessment indicated Resident #15 had Swan neck deformities in both of his hands.C. Resident observations and interviewsOn 4/6/26 at 3:01 p.m. Resident #15 was lying flat in bed. Both of his hands were concave at the knuckles, with the fingers extended out. Resident #15 said he had some pain in his hands from the deformity, but he did not want pain medication. Resident #15 said he could not bend his fingers, but would receive hand splints today (4/6/26) to help correct the deformity. He said he had worked with the therapy department for the past six weeks to get the hand splints.On 4/7/26 at 3:18 p.m. Resident #15 was lying flat in bed, taking a nap. The hand splints were observed in a basin on the opposite side of the room.On 4/8/26 at 10:30 a.m. Resident #15 was lying flat in bed. Resident #15 said the splints had arrived, but he had not gotten to wear them yet. Resident #15 said someone from the therapy department needed to put the splints on his hands.On 4/8/26 at 2:08 p.m. Resident #15 was lying flat in bed. Resident #15 said he had not seen anyone from the therapy department yet.D. Record reviewThe contracture care plan, initiated 4/7/25, identified Resident #15 had Swan neck contractures in both his hands. Interventions included offering Resident #15 orthotics and physical therapy and notifying the physician of any changes.The assistive devices care plan, revised 3/10/26, documented Resident #15 required assistive devices such as splints for his Swan neck contractures and occupational therapy would assist him with the splints.The plan of treatment for rehabilitation, dated 4/7/25, documented Resident #15 had not left his bed since his transition from rehabilitation to long-term care. The note documented that as a result, Resident #15 was functioning significantly below his baseline and would be referred to occupational therapy.-However, the plan of treatment did not address the swan neck deformities.The plan of treatment for rehabilitation, dated 12/8/25, documented Resident #15 said his goal was for his hands to work. The plan of treatment addressed the Swan neck deformity and included short-term and long-term goals to increase the range of motion in Resident #15's fingers. The note revealed Resident #15 was functioning at a higher level compared to his presentation on the day the note was written. The note documented a referral was placed for orthotics recommendation to an orthotics clinic.The occupational therapy progress notes, from 1/29/26 to 2/25/26, documented the facility contacted the orthotics clinic to assess Resident #15. The note documented Resident #15's hand and finger function were limited by the need for splinting.The occupational therapy progress note, dated 4/6/26 and written by occupational therapy assistant #1, documented Resident #15's splints had arrived at the facility. C. Staff interviewsOccupational therapy assistant #1 was interviewed on 4/6/26 at 3:01 p.m. Occupational therapy assistant #1 said he did not know when Resident #15 developed the Swan neck deformities in his hands. Occupational therapy assistant #1 said the therapy department had been treating the deformities with diathermy (electromagnetic current therapy), which had improved the condition marginally. Occupational therapy assistant #1 said Resident #15 was currently being fitted for hand splints by the orthotics clinic. The director of rehabilitation was interviewed on 4/9/26 at 12:43 p.m. The director of rehabilitation said Resident #15 had been admitted to the facility with the Swan neck deformities in his hands. The director of rehabilitation said that on 11/30/25 Resident #15 was screened by therapy services and was found to have had a significant decline in function. The director of rehabilitation said Resident #15 was functional after he completed rehabilitation, but at the time of the screening on 11/30/25, his hand and ankle contractures had worsened. The director of rehabilitation said at the time of the screening, Resident #15 said his goal was to be able to use his hands again, which prompted the therapy department to place the referral for hand splints. The director of rehabilitation said the standard treatment for Swan neck deformities was stretching, diathermy and splinting. The director of rehabilitation said Resident #15's Swan neck deformities would not improve without splinting. The director of rehabilitation said Resident #15 did not receive hand splints when he was admitted to the facility, because the rehabilitation department was focused on his lower extremity mobility.The DON was interviewed on 4/9/26 at 2:16 p.m. The DON said if a resident declined in their ability to perform ADLs or had a change in clinical presentation, nursing staff should inform the interdisciplinary team (IDT). The DON said splint management was managed by the rehabilitation department.

Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#16) of one resident out of 39 sample residents. Specially, the facility failed to ensure Resident #16's medical orders for scope of treatment (MOST) form matched the physician's order for cardiopulmonary resuscitation (CPR).Findings include:I. Resident #16A. Resident statusResident #16, age [AGE], was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included fracture of unspecified part of neck of left femur and asthma.The [DATE] minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of nine out of 15. She required set-up assistance with eating and oral hygiene and partial to moderate assistance with toileting hygiene and dressing. B. Record reviewResident #16's MOST form, which was located in a binder at the nurses' station and uploaded into the resident's electronic medical record (EMR), revealed that the form was signed on [DATE] by Resident #16's representative. The MOST form was additionally signed by the director of nursing (DON) on [DATE]. Review of Resident #16's MOST form revealed the resident/resident's representative wished for no CPR with selective treatment, including intravenous (IV) antibiotics and fluids. Additional wishes for the resident documented on the form included the resident wished to not be intubated (tube placed in the windpipe to keep airway open) and to avoid intensive care. The [DATE] CPO revealed a physician's order which indicated that Resident #16's code status (preference for CPR or no CPR should the resident's heart stop beating)was to receive CPR, ordered [DATE]. -However, the [DATE] CPO did not match with the directive on the MOST form, which indicated the resident wished to have no CPR, effective [DATE] (see MOST form above). A care conference progress note, dated [DATE], revealed the care conference was attended by Resident #16's representative, the social services director (SSD), and the assistant director of nursing (ADON). The progress note documented that a new MOST form was completed for Resident #16.-The note did not reveal that the resident's preferences for code status were changed.The care plan, initiated [DATE], revealed Resident #16's code status was CPR.-However, Resident #16's MOST form was updated on [DATE] to indicate the resident did not want CPR. II. Staff interviewsCertified nurse aide (CNA) #7 was interviewed on [DATE] at 4:23 p.m. CNA #7 said she had worked at the facility for one month and had six years of CNA experience. CNA #7 said if she had found Resident #16 and the resident had stopped breathing, she would have checked if the resident was on oxygen, ensured it was working, checked the resident's oxygen levels, obtained an oxygen concentrator if needed and notified the nurse right away. CNA #7 said the residents' code statuses could be found in the residents' EMRs and in the care plans. CNA #7 said Resident #16 was a full code status with CPR, based on the resident's EMR. CNA #7 said she had not seen a situation where the resident's EMR indicated CPR while the MOST form indicated no CPR, but she would have still provided care and kept the resident comfortable regardless of code status.Registered nurse (RN) #3 was interviewed on [DATE] at 4:36 p.m. RN #3 said if she had found Resident #16 unresponsive, she would have checked the resident's vital signs if the resident had no pulse and was not breathing. RN #3 said if there were no vital signs, she would have called the physician, applied oxygen or increased the oxygen and followed the physician's directions. RN #3 said Resident #16's code status could be found in the resident's EMR. RN #3 said she would follow the most recent MOST form if there was conflicting information.RN #5 was interviewed on [DATE] at 4:50 p.m. RN #5 said she had worked at the facility for one year. RN #5 said if she found Resident #16 unresponsive, she would have checked the resident's heart rate, vital signs and oxygen. RN #5 said that if the resident had no pulse and was not breathing, she would have checked the resident's code status and the medication administration record (MAR). RN #5 said Resident #16's code status could be confirmed in the EMR RN #5 said Resident #16 was a full code status, according to the resident's EMR. RN #5 said she would have followed the most recent MOST form if there was conflicting information and she would have notified the DON to determine why the physician's orders for code status had not been updated.The SSD was interviewed on [DATE] at 12:40 p.m. The SSD said nursing staff typically ensured that the residents' MOST forms, physician's orders for code status and EMRs matched. The SSD said the MOST form for Resident #16 was changed on [DATE] and the resident's representative, the DON and the SSD participated. The SSD said Resident #16's MOST form was coded as DNR (do not resuscitate) with selective treatment. The SSD said if there was a discrepancy in the EMR, she would have reviewed the MOST form during the care conference and discussed with the DON to resolve it.The DON was interviewed on [DATE] at 1:50 p.m. The DON said the facility ensured residents' code status was consistent between the MOST form, the physician's orders, and the residents' EMRs through care conference review. The DON said the staff members completing the clinical care conference, including the DON and the SSD, were responsible for updating the MOST form. The DON said staff were expected to follow the MOST form when there was conflicting code status information in the chart. The DON said care conferences were conducted quarterly to monitor and identify discrepancies.

Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individual providing services for one (#47) of two residents reviewed for hospice care services out of 39 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication would be documented between the facility and the hospice provider for Resident #47; and, -Ensure hospice agency staff notes were easily accessible to the facility staff and included consistent documentation of hospice care visits for Resident #47.Findings include: I. Facility policy and procedure The Hospice Service Facility Agreement policy and procedure was provided by the nursing home administrator (NHA) on 4/9/26 at 4:42 p.m. It read in pertinent part, The written agreement(s) will set out at least the following: a communication process, including how the communication will be documented between the facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day. The facility will, under a written agreement, ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.II. Resident #47A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included hypertensive heart disease, atherosclerotic heart disease, senile degeneration of the brain, restlessness and agitation. The 3/6/26 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of five out of 15. She used a wheelchair. She required partial assistance with eating and required substantial assistance with personal hygiene. She was dependent on oral hygiene, toileting, and showering, The assessment revealed the resident was receiving hospice care services. B. Resident's representative interview Resident #47's representative was interviewed on 4/6/26 at 4:03 p.m. The representative said Resident #47 was admitted to the facility because the resident's representative was no longer able to care for her at home because Resident #47 had dementia and required more supervision. The resident's representative said Resident #47 had fallen a couple of times since she was admitted to the facility and the hospice care services company had provided a Broda chair (a specialized wheelchair) to help prevent the resident from falling. C. Observations On 4/7/26, at 12:50 p.m. Resident #47 was escorted to the dining room by two hospice staff members. The hospice staff members immediately left the dining room. Resident #47 was in a Broda chair. -However, review of Resident #47's electronic medical record (EMR) did not reveal documentation of the hospice staff visit with Resident #47 (see record review below).On 4/8/26 at 12:01 p.m., Resident #47's room was observed. Resident #47's bed had an air mattress and a lipped mattress (a raised supportive perimeter mattress used to help prevent falls).-However, review of Resident #47's EMR did not reveal documentation that the durable medical equipment (DME) had been supplied by the hospice care services company (see record review and interviews below). D. Record review The hospice care plan, revised 3/11/26, revealed Resident #47 received hospice care services due to senile degeneration of the brain (a progressive, age-related decline in cognitive function caused by brain cell damage). Interventions included contacting the hospice agency for any change in condition, coordinating cares between the hospice agency and facility staff, educating staff to resident's needs and desires, encouraging socialization and activity as resident desired and was able; honoring advance directives, monitoring for complaints of pain or discomfort and providing interventions as orders, providing medication as ordered and providing ongoing emotional support to the resident and family members. The fall care plan, revised 3/11/26, revealed Resident #47 was at risk for falls due to terminal agitation, poor safety awareness, unable to retain new learning, noted to be restless at times and may cause slip from bed or chair. Interventions included assessing the resident's wheelchair for an alternative option, hospice was notified for a volunteer to sit with the resident, hospice was to perform a medication review; medication review by hospice for restlessness, and adjusting air mattress firmness for comfort. Review of Resident #47's April 2026 CPO revealed the following physician's orders: Admit to hospice with a terminal diagnosis of senile degeneration of the brain, ordered 2/20/26. -A review of Resident #47's EMR revealed no documentation to indicate hospice volunteer services were requested (see care plan above). -A review of Resident #47's EMR revealed no hospice notes were documented from 3/25/26 to 4/9/26. -Additionally, a review of Resident #47's EMR revealed no documentation to indicate a Broda chair and a lipped mattress were provided by the hospice care services company. III. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/9/26 at 9:46 a.m. LPN #1 said she knew a resident received hospice care services based on a physician's order. She said she knew a hospice worker visited if they came during her shift. She said she thought the director of nursing (DON) and the social services director (SSD) were the hospice coordinators for the facility. She said hospice was responsible for providing residents with DME, such as wheelchairs and mattresses. She said Broda chairs were used when residents were extremely agitated or terminally agitated. She said sometimes residents would slide out of a regular or high back wheelchair and a Broda chair was recommended. She said a Broda chair was a way for a resident to get out of their bed and still be able to sleep comfortably in a chair. She said a Broda chair was harder for residents to get out of the Broda chair. She said if a resident was on hospice, hospice completed the evaluation and assessment. She said she did not document if a resident had a Broda chair. She said a lipped mattress was used for the same reason, when a resident was more at risk for rolling out of bed. She said she was familiar with Resident #47. She said the resident had a Broda chair to help prevent her from falling. She said she did not remember when the Broda chair was delivered but thought it was about two weeks ago and hospice provided the Broda chair. -However, there was no documentation in the resident's EMR of an evaluation and assessment completed by hospice for the Broda chair or lipped mattress (see record review above).The DON was interviewed on 4/9/26 at 12:49 p.m. The DON said she was the hospice coordinator for the facility. She said nursing knew a resident received hospice care services based on change of shift report and on the face sheet. She said the hospice care services company was responsible for any DME needs the resident might have. The DON said hospice staff checked in with the floor nurse and the floor nurse entered a progress note regarding the hospice visit. The DON said hospice staff checked in with her as well. The DON said she was familiar with Resident #47. She said the resident had a Broda chair and a lipped mattress for safety and the hospice care services company had provided it. She said she did not know the hospice notes were not available in Resident #47's EMR.

Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one (#4) of six residents reviewed for accident hazards out of six sample residents. Specifically, the facility failed to ensure staff followed the appropriate transfer techniques when transferring residents, which resulted in Resident #4 sustaining rib fractures following a fall that occurred during an improper transfer with CNA #1.Resident #4, who had a history of falling, was admitted on [DATE] and readmitted on [DATE]. The resident had the ability to transfer to and from a bed to a chair (or wheelchair) with substantial/maximal assistance from staff (staff performed more than half of the effort by lifting or holding the resident's trunk or limbs and providing more than half the effort).On 7/11/25 Resident #4 was being assisted by certified nurse aide (CNA) #1 to transfer from her bed to her wheelchair. According to the facility's incident report, completed by licensed practical nurse (LPN) #1 on 7/11/25, CNA #1 reported that Resident #4 was sitting on the edge of her bed with her wheelchair beside the bed and CNA #1 was positioned behind the resident's wheelchair. The resident attempted to transfer, became weak and went down to the floor. CNA #1 reported she was unable to get around the wheelchair quick enough to prevent the resident from falling to the floor. Resident #4 was assessed by registered nurse (RN) #1 and was able to move all of her extremities and her vital signs were within normal limits. The resident sustained a hematoma (solid swelling of clotted blood within the tissues) to the left side of her forehead with bruising (localized area of discoloration on the skin caused by trauma or injury) to the left eye area.On 7/12/25 Resident #4 was transferred to the hospital for tachycardia (fast heartrate) with labored breathing utilizing urgent transportation. While at the hospital, a computerized tomography (CT) scan of Resident #4's head, cervical spine, and chest/abdomen/pelvis was completed due to the resident's fall on 7/11/25. The CT scan of the resident's chest revealed she sustained an acute, mildly displaced fracture of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib from the fall.According to an interview with the nursing home administrator (NHA) during the survey, CNA #1 was given a verbal reprimand related to making sure the resident wore appropriate footwear before the transfer on 7/11/25 (see NHA interview below).-However, there was no documentation to indicate CNA #1 was provided with re-education on transferring residents following the incident with Resident #4 on 7/11/25 to ensure she was using the appropriate transferring technique when transferring residents with a gait belt.The facility's failure to ensure staff followed the facility's appropriate transfer technique when transferring residents resulted in Resident #4 sustaining rib fractures following a fall that occurred during an improper transfer with CNA #1.Findings include:I. Professional referenceAccording to Treas, L., [NAME], K. and [NAME], M. (2022) [NAME] Advantage for Basic Nursing (3rd ed.), pp. 1237-1238, Transferring a patient from bed to chair: stand toward the bed facing the patient. Brace your feet and knees against the patient's legs. Pay particular attention to any known weaknesses. Bend your hips and knees, and keeping your back straight, hold onto the transfer (gait) belt on both sides. Bracing provides stability.II. Facility policy and procedureThe Fall Prevention Program policy, dated 2024, was provided by the NHA on 10/27/25 at 12:02 p.m. The policy revealed each resident would be assessed for fall risk and would receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. A fall was described as an event in which an individual unintentionally came to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (such as a resident pushing another resident). The event might be witnessed, reported, or presumed when a resident was found on the floor or ground, and could occur anywhere.The facility utilized a standardized risk assessment for determining a resident's fall risk. The risk assessment categorized residents according to low, moderate, or high risk. For program identification purposes, the facility utilized high risk and low/moderate risk, using the scoring method designated on the risk assessment. The low/moderate risk protocols included implementing universal environmental interventions that decreased the risk of resident falling, including encouraging residents to wear shoes or slippers with non-slip soles when ambulating.Staff were also to monitor for changes in a resident's cognition, gait, ability to rise/sit, and balance.Each resident's risk factors and environmental hazards would be evaluated when developing the resident's comprehensive plan of care. Any interventions would be monitored for effectiveness and the resident's plan of care would be revised as needed.When any resident experienced a fall, the facility would assess the resident, complete a post-fall assessment, complete an incident report and notify the resident's physician and family. The facility would also review the resident's care plan and update as indicated. The facility would further document all assessments/actions and obtain witness statements in the case of injury.The Activities of Daily Living (ADL) policy, dated 2024, was provided by the NHA on 10/29/25 at 9:05 a.m. The policy revealed the facility would, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs did not deteriorate unless deterioration was unavoidable. Care and services would be provided for transfers, toileting and ambulation. The facility would maintain individual objectives of the care plan and periodic review and evaluation. III. Facility's transfer in-service trainingThe NHA provided the Transfer a Resident in-service (slides) on 10/29/25 at 12:31 p.m. The NHA said the in-service training was mandatory for nursing staff upon hire and during the annual staff in-services. The in-service slides revealed the following:Slide #5: staff were to use a gait belt on the resident if the resident could not stay upright on their own. If the resident had suffered a stroke or had other issues that affected their motor functions, staff were to attach a gait belt around their waist. The gait belt would give a better grip during the transfer so the resident did not fall out of the staff member's arms. Staff were to wrap the gait belt around the resident's waist so it was snug, but not too tight. Staff were to tuck any extra fabric at the end of the belt into the belt so it was not a tripping hazard. Staff were not to use the gait belt as a handle or a way to pick up the resident. The purpose of a gait belt was to create friction when staff lifted the resident so that they did not fall.Slide #6: staff were to lock their hands behind the resident or at the gait belt. Staff were to stand as close as possible to the resident and reach around the resident's chest with their hands. Staff were to lock their hands together behind the resident, at the resident's mid-back area. If the resident had a gait belt on, staff could hold the gait belt between their hands and line up their hands with the belt to create friction.Slide #7: staff were to place the resident's outside leg between their knees. The resident's outside leg would be the leg furthest from the chair. Staff were to position the resident's leg between their knees for support and bend their knees, keeping their back straight. Staff were to tell the resident they were going to count to three, and on three, the staff person was going to stand up and lift the resident. Staff were to make sure the resident kept their hands by their sides so they could support themselves when they lifted them. If the resident had strength in their legs, staff were to instruct the resident to support their weight with their legs as the staff person transferred them.Slide #8: staff were to stand and lift the resident and pivot towards the chair. Staff were to count aloud one, two three and on three, slowly stand up and use their legs (not their back) to lift the resident. Staff were to lift the resident and ask the resident to push off the bed using their hands. Staff were to shift the resident towards the chair, making sure the staff's back was aligned with their hips.Slide #9: staff were to lower the resident into the chair. Once the resident's legs touched the seat of the chair, staff were to bend their knees and slowly lower the resident into the seat. Staff were to have the resident reach for the armrests to support themselves as they lowered them down. If the staff were lowering the resident into a wheelchair, the staff could then reposition the feet guards and instruct the resident to put their feet in the guards so they were well supported in the chair. Staff were to confirm the move went well by asking the resident, How do you feel? or Feeling okay in the chair? If the resident answered yes, staff could wheel the resident away in the chair or let them sit in the chair on their own.IV. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, dependence on supplemental oxygen, history of falling, cerebrovascular disease and bilateral primary osteoarthritis of the hips.According to the 7/2/25 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 of 15. The resident did not have any impairments with functional limitations in ranges of motion. The resident utilized a wheelchair for ambulation. The resident had the ability to transfer to and from a bed to a chair (or wheelchair) with substantial/maximal assistance from staff. The resident received scheduled pain medication.B. Resident interviewResident #4 was interviewed on 10/27/25 at 1:50 p.m. Resident #4 said she did not remember her fall on 7/11/25 or that she had sustained any injuries from a fall. The resident did not appear to be in any pain and said she was treated well by staff.C. Incident report for Resident #4's witnessed fall on 7/11/25The incident report, dated 7/11/25 at 7:50 a.m., and documented by LPN #1, revealed Resident #4 had a witnessed fall on 7/11/25. The resident was being assisted with a transfer by CNA #1 and in the process of the transfer, the resident lost her balance and made contact with the floor. The resident denied any pain at the time of the fall and did not display any body language of being in any distress. RN #1 assessed the resident before any movement. The resident remained at her baseline and was alert to person, place, time and situation. The resident had a hematoma to the left side of her forehead with bruising to the left eye area. The resident was able to move all of her extremities and her vital signs were within normal limits. Neurological assessments were initiated. The director of nursing (DON), the resident's family and the physician were notified. The statement made by CNA #1 revealed Resident #4 was sitting on the edge of her bed with her wheelchair beside the bed. CNA #1 was positioned behind the resident's wheelchair. The resident attempted to transfer, became weak and went down to the floor. CNA #1's statement revealed she was unable to get around the wheelchair quickly enough to prevent the resident from falling to the floor. The root cause analysis of the event revealed Resident #4 became weak and lost her balance.D. Record reviewA Fall Risk Tool, dated 2/26/25 at 3:29 p.m., revealed Resident #4 was a moderate fall risk.A care plan for being at risk for falls related to weakness, respiratory failure and arthritis was revised on 10/1/23. The interventions included to keep Resident #4's environment free from clutter. The staff were to utilize a one-person transfer with a gait belt. -The care plan did not direct the staff to ensure the resident wore appropriate footwear for transfers (see DON interview below). A care plan for ADLs related to decreased mobility as evidenced by muscle weakness, lack of coordination, arthritis and respiratory failure was revised on 10/1/23. The interventions included that Resident #4 required one-person assistance with bed mobility and use of a wheelchair for mobility. Staff were to utilize a one-person transfer with a gait belt. -The care plan did not direct the staff to ensure the resident wore appropriate footwear for transfers (see DON interview below). A physician's note, dated 7/11/25 at 8:06 a.m., revealed Resident #4 was seen on 7/11/25 due to a fall that morning. The resident was reported to have struck her head. The resident had a laceration (cut or tear in the skin) on the left upper frontal area of the head with a contusion (injury where blood vessels beneath the skin were damaged, leading to discoloration and swelling). The resident reported some tenderness in the area and a bit of a headache, which had not worsened with severity. The resident was okay not to be sent to the hospital currently, but might require a transfer to the hospital if her symptoms worsened for a CT scan of the head related to the use of an anticoagulant (blood thinning) medication. The note further revealed Resident #4 had a large hematoma to the left side of her forehead and a photo was taken of the area. The resident's neurological assessments were stable and the use of the anticoagulant medication was discontinued. The physician discussed goals of care with the resident regarding possible transfer to the hospital should she need to go and she was amenable to such. The resident would be transferred to the hospital if there was any evidence of clinical decompensation.A nurse note, dated 7/11/25 at 10:29 a.m. and documented by LPN #1 revealed Resident #4 was being assisted with a transfer. During the transfer, the resident lost her balance and made contact with the floor. The resident denied any pain at the time and did not show any body language of being in any distress. RN #1 assessed the resident. The resident remained at baseline and was alert. The resident had a hematoma to the right side of her forehead. The resident was able to move all of her extremities and her vital signs were within normal limits. Neurological assessments were initiated. The resident's physician, family and the DON were notified.A nurse note, dated 7/12/25 at 2:26 a.m. and documented by a LPN, revealed Resident #4 continued on follow-up due to a recent fall. The resident had a raised hematoma to the left brow line. The resident said she had no pain related to the fall. The resident denied needing/wanting an ice pack or medication for pain. The resident's vital signs were at baseline and her neurological assessments were within normal limits. The resident rested quietly in bed with her eyes closed. The resident's respirations were even and unlabored with no physical indications of pain or acute distress.An eINTERACT transfer form, dated 7/12/25 at 2:47 a.m., revealed Resident #4 was transferred to the hospital. The resident had a raised hematoma to the left brow line related to a mechanical fall (caused by external or environmental factors like slipping, tripping, or stumbling, where the person did not first lose consciousness) on 7/11/25 at 8:00 a.m. The resident also had bruising and swelling (accumulation of fluid) to the left side of her face. The resident did not have any pain at the time of the transfer to the hospital.A nurse note, dated 7/12/25 at 3:11 a.m., revealed Resident #4 was sent to the hospital for tachycardia with labored breathing utilizing urgent transportation. The resident's family and the physician were notified of the transport.Review of the emergency department (ED) documentation revealed Resident #4 was admitted to the ED on 7/12/25 at 3:17 a.m. The diagnoses were unspecified fall, contusion of part of the head, multiple fractures of the ribs on the left side and altered mental status. The documentation revealed the resident fell early yesterday morning (7/11/25), approximately 24-hours prior to presentation. After the fall, the resident was helped up and put back to bed. A facility doctor evaluated her and recommended holding her dose of apixaban (blood thinner) for the day. The resident was reported to be behaving normally for the rest of the day, at her baseline of alert and oriented to person, place, time, and situation. The resident was noted to be quite functional, communicating with family via her computer and organizing her own medications with some assistance. The resident was observed to be at her baseline at approximately 10:45 p.m. At approximately 2:45 a.m. the resident was found to have garbled speech and was altered and confused, which was a change from her baseline. Emergency medical services (EMS) was called and observed the resident to have garbled speech, inappropriate answers to questions, and slurred speech. Upon arrival at the emergency department, Resident #4 was able to state her name but answered I don't know to most other questions and was not reliably following commands. The resident had a large hematoma and bruising which has worsened over the course of the day. A partial trauma activation was initiated. Imaging included a CT scan of the head, cervical spine, and chest/abdomen/pelvis. The CT scan of the chest revealed an acute, mildly displaced fracture of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib. The resident denied any current pain, including head pain.A nurse note, dated 7/12/25 at 9:07 p.m. and written by RN #1 revealed Resident #4 returned to the facility at approximately 5:50 p.m. from the hospital by ambulance with two paramedics. The resident's family was in attendance. The resident was assisted into bed, was alert and responded appropriately. The resident denied any pain or discomfort. The resident's lungs were clear, with no cough or congestion. The resident would be started on an antibiotic for a urinary tract infection. No new skin issues were observed.A nurse note, dated 7/13/25 at 2:59 a.m. and written by a LPN revealed Resident #4 was readmitted after a brief hospitalization for altered mental status with hypoxia, tachycardia, and nausea with one episode of emesis. The resident returned with a diagnosis of a urinary tract infection and was started on an antibiotic. The resident was also diagnosed with multiple rib fractures to include fracture of the left anterior third rib and a non-displaced fracture of the left anterior fourth rib from a mechanical fall. The resident also had a further diagnosis of traumatic ecchymosis (discoloration of the skin resulting from bleeding underneath, typically caused by bruising) of the face. The resident utilized supplemental oxygen at three liters per minute via a nasal cannula and was stable at 90%. Staff were unable to determine if the resident's respirations were shallow related to the rib fractures because the resident was unable to state the cause, however she denied any pain. The resident's daughter accompanied the resident back to the facility from the hospital and was aware of the resident's current medical status. The resident's respirations were even and unlabored with stable oxygen saturation with the administration of three liters per minute. The resident had no physical indications of pain or acute distress. The resident's vital signs revealed increased respirations and slight tachycardia with 90 heartbeats per minute. The resident's neurological assessments were reinstated upon her return to the facility for the remainder of the 72-hour post fall assessments.A nurse note, dated 7/13/245 at 8:48 p.m., revealed Resident #4 continued on 72-hour neurological assessments for a recent fall with a hospitalization. The neurological assessments remained within normal limits. The resident had a pain level of 2-3 out of 10, which was relieved by Tylenol. The resident had facial bruising and her vital signs were at baseline. The resident's respirations were even and unlabored with no objective signs of acute distress.The skin observation tool, dated 7/17/25 at 11:57 p.m., revealed Resident #4's skin was intact (no abrasions, bruises, rashes or open areas).-However, the resident had bruising to the left eyebrow and face (see DON interview below).A typed phone interview note, dated 10/28/25 (not timed), with CNA #1 was provided by the NHA on 10/29/25 at 9:08 a.m. The typed statement revealed CNA #1 was assisting Resident #4 with her transfer from the bed to the wheelchair (on 7/11/25). After helping the resident sit at the edge of the bed with her feet flat on the floor, CNA #1 placed slip-on shoes (no backs) on the resident. CNA #1 applied a gait belt on the resident. The resident's wheelchair was positioned securely at the resident's beside at a slight angle. The brakes were locked on the wheelchair. Due to the limited space in the room, CNA #1 assisted Resident #4 from the side. CNA #1 maintained a firm grip on the gait belt using an upward grasp at the hips. As the resident began to pivot to sit in the wheelchair, her shoe (with no back) became lodged (stuck in position or place) at a wheel, causing the resident to lose her balance and fall forward. Despite assisting the resident from the side to guide her pivot, CNA #1 was unable to prevent the fall when Resident #4's shoe caught upon one wheel. Immediately after the incident, CNA #1 remained with the resident, and immediately called the nurse and a LPN.V. Staff interviewsLPN #1 was interviewed on 10/27/25 at 2:40 p.m. LPN #1 said Resident #4 was a one-person transfer with the use of a gait belt before the fall that occurred on 7/11/25. She said she completed the incident report dated 7/11/25 at 7:50 a.m. for the resident's witnessed fall. She said the incident report included the statement made by CNA #1. LPN #1 said the statement revealed Resident #4 was sitting on the edge of her bed with her wheelchair beside the bed and CNA #1 was positioned behind the resident's wheelchair. LPN #1 said the resident attempted to transfer, became weak and went down to the floor. She said CNA #1's statement also revealed the CNA was unable to get around the wheelchair quickly enough to prevent the resident from falling to the floor. LPN #1 said RN #1 did an assessment of the resident before the resident was moved from the floor.The DON was interviewed on 10/28/25 at 5:30 p.m. The DON said Resident #4 was a one-person gait belt transfer. The DON said RN #1 did an assessment of the resident before the resident was moved from the floor (on 7/11/25). The DON said the resident did eventually go to the ED. The DON said the resident lost her balance while she was turning to sit in the wheelchair and fell.The minimum data set (MDS) coordinator was interviewed on 10/29/25 at 9:28 a.m. The MDS coordinator said according to the resident's MDS assessment dated [DATE], Resident #4 was a substantial/maximal one-person gait belt assist for transfers.CNA #1 was interviewed by phone on 10/29/25 at 10:00 a.m. CNA #1 said she was getting Resident #4 up for her breakfast (on 7/11/25). She said the resident was sitting on the bed and she placed the resident's shoes (with no backs) on the resident's feet. on. CNA #1 said she got the resident's wheelchair ready and angled the right front of the wheelchair toward the side of the bed. She said she placed the gait belt on the resident and locked the brakes on the wheelchair. CNA #1 said she helped the resident stand up and began the stand-to-pivot maneuver toward the wheelchair. CNA #1 said she had her hands on the gait belt and was standing in a side-assist hip-to-hip position with Resident #4. CNA #1 said one of the resident's shoes became hung on a wheelchair wheel and the resident started falling forward. CNA #1 said she was unable to prevent the fall because she could not get around the wheelchair quick enough. She said she was not in front of the resident to prevent the fall. CNA #1 said she stayed with the resident until LPN #1 arrived. CNA #1 said RN #1 completed the assessment of the resident while the resident remained on the floor. She said the resident was removed from off the floor with the assistance of two staff members and the use of a gait belt. She said Resident #4 was not in a lot of pain and was not bleeding to her knowledge. CNA #1 said she was not behind the wheelchair as was stated in the incident report statement (see above). CNA #1 said the resident's nightstand and a bedside table took up a lot of space in the room and she did the side assist to allow more room for the transfer. CNA #1 said she should have been standing in front of Resident #4 and utilized an upward firm grasp on the resident's gait belt prior to the pivot transfer.RN #1 was interviewed by phone on 10/29/25 at 11:23 a.m. RN #1 said he assessed Resident #4 before she was removed from the floor on 7/11/25. He said she was not yelling out in pain and there was no bleeding. He said the resident had a large hematoma on her head. He said he also performed an overall assessment on the resident. He said the resident did not report any pain in the bony areas. He said he did not recall if the resident had any pain in the rib cage area. He said neurological assessments were started and he was unable to recall the resident's transfer status.CNA #2 was on 10/29/25 at 11:35 a.m. CNA #2 said she had worked with Resident #4. She said the resident was a one-person gait belt transfer. She said the resident was also a stand-to-pivot for transfers. She said to transfer the resident when seated on the bed, she would place the wheelchair in front of the resident. CNA #2 said she would be standing in front of the resident, place her hands on the gait belt and pivot the resident into the wheelchair. She said if the resident happened to fall forward, in this position, she would be able to safely guide the resident to the wheelchair or the floor. CNA #2 said this methodology of transferring the resident was the safest and easiest way to transfer Resident #4. She said the resident was usually strong and she had not had any issues with transfers with her.CNA #3 was interviewed on 10/29/25 at 11:45 a.m. CNA #3 said she had worked with Resident #4. She said the resident was a one-person gait belt strand to pivot transfer. She said if the resident was seated on the bed, she would either place the wheelchair in front of the resident or at an angle with the front of the wheelchair closest to the bed. She said if she were in front of the resident, she would place both hands on the gait belt and pivot the resident into the wheelchair. She said if she were in front of the resident, she would be able to protect the resident from a fall easier. She said there were times she placed the wheelchair at an angle and positioned herself between the bed and the wheelchair. She said she would place her hand on the gait belt on the resident's back and assist with the transfer. She said she would not know how she would protect the resident from falling forward using this method for transfers.The DON was interviewed again on 10/29/25 at 12:42 p.m. The DON agreed the staff were taught how to transfer a resident with a gait belt by the Transferring a Resident training slides. The DON said the slides demonstrated that staff were to be straight on (in front of) with the resident, hold onto the gait belt and then pivot the resident to the wheelchair. The DON said Resident #4 was a one-person gait belt stand-to-pivot for transfers. The DON said the weekly skin assessment dated [DATE] revealed the resident had no skin issues (bruising) and this was incorrect. She said the resident had bruises on the left side of her eye orbit, forehead and cheek. She said the resident fell forward onto the floor during the transfer with CNA #1 on 7/11/25. The DON agreed with the 7/12/25 hospital CT scan results. The DON said the facility wanted all residents to be transferred safely and staff were to transfer residents with gait belts according to the Transfer a Resident in-service slides (see above). The DON said during the morning meetings, falls were discussed and part of the risk management portion for falls included any environmental contributing factors. The DON said LPN #1's progress note nor the incident report for Resident #4's fall mentioned any environmental issues as contributing factors to the fall.The NHA was interviewed on 10/29/25 at 1:38 p.m. The NHA said the provided Transfer a Resident in-service slides were reviewed for the all staff meetings on 7/31/24 and 7/15/25. He said CNA #1 was hired on 6/19/25 and had completed/demonstrated competency in resident transfers. The NHA said facility staff should transfer residents according to the in-services unless therapy made different recommendations. The NHA said CNA #1 was given a verbal reprimand related to making sure the resident wore appropriate footwear before the transfer on 7/11/25.

Based on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for two (#3 and #9) of three residents reviewed for falls out of seven sample residents. Specifically, the facility failed to have a registered nurse (RN), nurse practitioner or physician assess the residents after unwitnessed falls, prior to the removal of the residents from off the floor. Findings include: I. Facility policy The Falls and Fall Risk Managing policy, revised January 2024, was provided by the nursing home administrator (NHA) on 8/20/24 at 8:31 a.m. The policy revealed on previous evaluations and current data, the staff would identify interventions related to the resident's specific risks/causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the minimum data set, (MDS) a fall was defined as an unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force; such as a resident pushed by another resident. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, would be considered a fall. A fall without injury was still considered a fall. Unless there was evidence suggesting otherwise, when a resident was found on the floor, a fall was considered to have occurred. The staff, with the input of the attending physician, would 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 a resident's fall risk identified several possible interventions, the staff might choose to prioritize interventions, such as trying one or a few at a time, rather than many at once. Examples of initial approaches might include exercise and balance training, rearrangement of room furniture, improving footwear, and/or changing the lighting. If falling recurred despite initial interventions, staff would implement additional or different interventions, or indicate why the current approach remained relevant. If the underlying causes could not be readily identified or corrected, staff would try various interventions, based on an assessment of the nature or category of falling, until falling was reduced or stopped, or until the reason for the continuation of the falling was identified as unavoidable. The Fall policy, not dated, was provided by the NHA on 8/20/24 at 11:18 a.m. The policy revealed a post fall physical head to toe assessment should be conducted by a licensed nurse. If spinal cord injury was suspected, staff were to ensure the resident's neck/head were stabilized, the resident should remain as still as possible, and staff would call emergency services (911). A licensed nurse and the interdisciplinary team (IDT) would evaluate the chain of events or circumstances preceding the fall. This would include: the time of day of the fall; the time of the last meal; what the resident was doing; whether the resident was standing, walking, reaching, or transferring from one position to another; whether the resident was among other persons or alone; whether the resident was trying to get to the toilet; whether any environmental risk factors were involved (such as a slippery floor, poor lighting, furniture or objects in the way); whether there is a pattern of falls for this resident; recent changes to medication and last administration of medication (narcotic, cardiac, psychotropic); the resident's location; the type of footwear; and the location of any assistive devices and call lights. The nursing staff would initiate the neurological evaluation flowsheet if a fall was unwitnessed or if the resident hit their head, or had a change in their mental status. A licensed nurse must initiate the first set of neurological vital signs and evaluation. A licensed nurse must fill out the entire time span of monitoring on the neurological evaluation flowsheet. A licensed nurse must follow the frequency outlined at the top of the neurological evaluation flowsheet. All areas on the neurological evaluation flowsheet must be filled out and completed. Any abnormal vital signs or evaluation findings must be notified to the resident's physician. II. Resident #3 A. Resident status Resident #3, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physicians orders (CPO), diagnoses included history of falling, abnormalities of gait/mobility, anxiety, heart failure, restless legs syndrome and wedge compression fracture of thoracic seven and eight vertebra. The 6/18/24 minimum data set (MDS) assessment identified the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out 15. The resident had no impairments in either the upper or lower extremities. The resident was independent in her ability to roll to her left and right side. The resident required supervision or touch assistance in her ability to walk at least 150 feet in a corridor or similar space, after she had stood upright. B. Resident interview Resident #3 was interviewed on 8/20/24 at 10:10 a.m. Resident #3 said for two of her falls, the mattress on her bed slid as she turned over in bed. She said she was asleep and then she woke up on the floor with the mattress on top of her. She said for both of the falls out of bed, she had to go to the hospital. She said she had a lot of all over body pain from each of the falls. She said she hit her head both times and had some bleeding but did not break anything. She said she still had some pain in her back. She said she did have sufficient pain medications. C. Record review The care plan for a history of falls, medication use, new environment and unsteady balance/gait was initiated on 2/26/24. The interventions included to provide the resident with a clutter free environment that was free from spills, provide the resident with adequate lighting and place personal items within reach. Staff were to ensure the call light was within reach and encourage the resident to use the call light. Nursing staff were to provide the resident with assistive devices as needed and refer the resident for therapy services as needed (initiated on 2/26/24). Nursing staff were to remind the resident to use the call light for safety which (initiated on 2/26/24). Nursing staff verbally educated the resident on the use of the call light, to ask for assistance as needed, and to use the proper footwear (initiated on 3/4/24). Nursing staff were verbally educated to anticipate the resident's needs and the visual cues for the use of the call light (initiated on 3/4/24). Staff were to provide the resident with non-slip socks and place the resident's walker within reach (initiated on 3/16/24). The resident was verbally educated to wait to undress at the toilet and not prior to going to the toilet (initiated on 3/16/24). Nursing staff were to provide visual cues for the resident to call for help as needed and staff were to anticipate the resident's needs (initiated on 3/18/24). Physical therapy and occupational therapy was approved and a cognitive evaluation to be performed by therapy (initiated on 3/18/24). The maintenance staff were to check the bed/mattress for proper fit (initiated on 3/23/24). The resident was currently working with physical therapy and occupational therapy (initiated on 3/23/24). Therapy services were to evaluate if a lipped mattress was appropriate for the resident (initiated on 3/29/24). The fall risk tool, dated 3/3/24 at 1:43 p.m., revealed the resident had a score of seven, or a moderate risk for falling. D. Fall 3/16/24 The incident report dated 3/16/24 at 8:45 p.m., revealed a certified nurse aide (CNA) reported to the nurse that during walking rounds the resident was found on the floor. Upon entering the room, the resident was found sitting upright and said she fell trying to get her shorts off to go to the bathroom. The resident was not wearing any footwear nor using her walker for assistance. The resident had been educated prior to the fall related to being a high fall risk and not wearing any kind of footwear. The resident said that she just forgot. A head to toe assessment was completed. The resident said she hit her head and there were no concerns observed during the assessment of her head. The resident's range of motion and vital signs were at her baseline (normal). There were no observed cognitive changes and the resident returned to bed with two staff members assistance. All appropriate parties were notified of the fall. The resident was provided with non-skid socks and her walker was placed within reach. Resident #3 was able to make all needs known and the call light was placed within reach. She reiterated she slipped trying to take her shorts off to go to the bathroom. The resident was oriented to person, place, time and situation. The interdisciplinary team (IDT) interventions were to provide the resident with non-slip socks and have her walker placed within reach. The resident was verbally instructed to wait to undress when at the toilet not prior to going to the toilet. -Resident #3's clinical record revealed the resident was not assessed by a registered nurse (RN), nurse practitioner (NP) or physician before the resident was assisted from off the floor, after the fall on 3/16/24. The pain assessment tool, dated 3/16/24 at 9:53 p.m., revealed the resident had a pain rating of 3 out of 10. The nurse note dated, 3/16/24 at 9:57 p.m. and written by a licensed practical nurse (LPN), revealed the resident was found sitting on the floor. Neurological assessments were initiated according to facility protocol. All appropriate parties were notified. E. Fall 3/18/24 The incident report, dated 3/18/24 at 6:30 a.m., revealed a CNA informed the nurse that the resident was lying on the floor outside of her room, near her door. The resident's feet were towards the door and her head was facing near the Sunlight hallway. The resident was lying on her back. The resident's mattress was off the frame of the bed. The resident sustained bruising to the left knee and bruising to the right shoulder/arm. The resident had a laceration to the right side of her head with obvious bleeding. The resident said she fell to the floor while getting out of bed to use the restroom. She said the mattress landed on top of her body and she crawled to the hallway to scream for help. A full set of vital signs were taken and the staff assisted the resident back to bed. The resident and staff were verbally educated on the importance of call light use. The staff were also verbally educated on the importance of assisting the resident to and from her bathroom. Nursing staff called emergency services and the resident was sent to the emergency department (ED) for an evaluation. All contacts were notified. The resident was oriented to person, place, time and situation. The IDT interventions were to provide visual cues for the resident to call for help when needed, staff to anticipate the resident's needs, physical/occupational therapies had been approved, and a cognitive evaluation would be completed by therapy. -Resident #3's clinical record revealed the resident was not assessed by a RN, NP or a physician before the resident was assisted from off the floor, after the fall on 3/18/24. The pain assessment tool dated 3/18/24 at 6:30 a.m., revealed the resident had a pain rating of 2 out of 10. The hospital documentation revealed the resident arrived at the emergency department (ED) on 3/18/24 at 7:01 a.m. The resident presented with a primary complaint of a fall. The resident was in her bed, fell off the side of the bed and the mattress fell on top of the resident. The resident said she felt the mattress was unstable and when she laid too far to the side, the mattress started to slide off the bed. The resident hit the back of her head either on furniture or on the floor. The resident denied any loss of consciousness and reported pain to the right posterior head and neck. The resident also had right shoulder pain. The computed tomography (CT) images of the head and cervical spine did not reveal any acute injuries. A right shoulder x-ray was obtained and no obvious fractures or any dislocation was observed. The nurse note, dated 3/18/24 at 10:03 a.m. and written by a LPN, revealed the resident was on follow-up for a fall with no injuries. The resident was observed on the floor in the morning and was sent to the ED for evaluation. The resident had a gash to the right side of her head with a bruise to her left knee. The nurse note, dated 3/18/24 at 11:00 a.m. and written by a LPN, revealed the resident had returned to the facility from the ED. All performed tests ruled out any abnormalities. The CT was negative. The resident received pain medication as requested for a headache with effectiveness. The resident was educated on the importance of using the call light and staff would continue to monitor. The fall risk tool, dated 3/18/24 at 11:04 a.m., revealed a score of 11, or a moderate risk for falling. F. Fall 3/23/24 The hospital ED progress note, dated 3/23/24 at 1:22 p.m., revealed the resident had fallen out of bed. The resident was reported to have been sitting on the edge of her bed while placing her socks on her feet. She slid off the bed onto her right buttock and she denied any head trauma. The resident said she was unable to stand unassisted and a large amount of bruising was observed to the right buttock. Pelvic and right hip x-rays did not reveal any acute bony abnormalities or other acute pathologies. The incident report, dated 3/23/24 at 2:29 p.m., revealed the nurse was called to the resident's room by a CNA, related to the resident lying on the floor. Upon entrance to the room, the resident was lying on her back by the side of the bed. The resident was assessed and it was determined the resident should be sent to the ED for evaluation. Management, the physician and the family were notified. The resident said she was trying to put her socks on and fell out of bed. The resident had an injury to her right buttock. The resident was helped by paramedics and staff to be placed on the stretcher and taken to the hospital ED. The IDT interventions were for maintenance to check the resident's bed/mattress for a proper fit. The resident was currently working with physical and occupational therapies. The pain assessment tool, dated 3/23/24 at 2:29 p.m., revealed a score of 3 out of 10. The nurse note, dated 3/23/24 at 2:43 p.m. and written by a LPN, revealed the resident was found on the floor by the side of the bed. The resident was lying flat on her back and her bottom, when the nurse arrived. The resident was assessed by two nurses, her hips looked dislocated and she was in pain. Emergency services were called. When the paramedics arrived, the resident received an injection of pain medication. The resident was taken to the hospital. Management, the physician and the family were notified. The ED was called and a report was provided. The fall risk tool dated, 3/23/24 at 2:49 p.m., revealed a score of nine, or a moderate risk for falling. -Resident #3's clinical record revealed the resident was not assessed by a RN, NP or physician before the resident was assisted from off the floor, for the fall on 3/23/24. III. Resident #9 A. Resident status Resident #9, age 82,was admitted on [DATE]. According to the August 2024 CPO, diagnoses included stage 3 chronic kidney disease, anxiety, asthma, chronic diastolic congestive heart failure and chronic obstructive pulmonary disease. The 6/8/24 MDS assessment identified the resident had moderate cognitive impairment with a BIMS score of 10 out 15. The resident had no impairments in her upper or lower extremities. B. Resident interview Resident #9 was interviewed on 8/20/24 at 12:11 p.m. She said the fall on 5/1/24 was her fault because the facility wanted her to stay in her bed and she did not. She said her right knee and foot were the cause of her fall. She said she did hit her head and her back still hurt at times. C. Record review The care plan for being at risk for falls related to medication use, a new environment, weakness, unsteady balance/gait and the use of a Hoyer lift was initiated on 12/15/23. The interventions included to keep her environment free from clutter, free from spills, provide adequate lighting and to ensure her personal items were within reach. Staff were to encourage the resident to keep her bed in the lowest position. The facility would request hospice to provide a bolster sheet to be applied to her air mattress. Staff were to ensure the call light was within reach and encourage the resident to use the call light. Staff were to ensure the resident used the appropriate footwear when ambulating. Staff were to review the documentation on past falls and attempt to determine the cause of the falls. Staff would apply the bolster sheet and ensure it fit the bed properly related to the resident leaning to the right (initiated on 5/1/24). Staff would modify the resident furniture placement to ensure snacks were within reach (initiated on 5/1/24). Staff were to offer the resident snacks when in the room (initiated on 5/1/24). The fall risk tool, dated 1/25/24 at 2:28 p.m., revealed a score of 11, or a moderate risk for falling. D. Fall 5/1/24 The incident report, dated 5/1/24 at 5:30 a.m., revealed the writer heard a shout for help. The resident had slid out of bed onto the floor. The resident was still upright when found. The resident received a scrape to the right side of her head that was approximately three inches in length. The resident was unaware of the injury and did not know how it had occurred. The resident said she was reaching for a snack that was out of reach. The resident was assessed head to toe and no other injuries were observed from the fall. The resident's range of motion was within normal limits. The resident was returned to bed with three staff assistance and the use of a gait belt. The resident denied any pain (0 out of 10) related to the fall. All parties were notified. The resident was resting quietly in her bed with her eyes closed and no physical indications of pain or acute distress were observed. The resident's bed was placed in the lowest position. The resident was oriented to person and place. The resident's room had been previously rearranged by her granddaughter's preference for more room between the dresser and the bed. The IDT interventions were to ensure a bolster sheet was properly fitted to the bed related to the resident had a tendency to lean to the right. The resident's furniture was modified to ensure snacks were within reach. Staff were to offer snacks when they were in the room. A nurse note, dated 5/1/24 at 5:30 a.m. and written by a LPN, revealed the resident had an unwitnessed fall from the bed that resulted in a small laceration to the right scalp area. All appropriate parties were notified. The fall risk tool, dated 5/1/24 at 11:15 a.m., revealed a score of 16, or a high risk for falling. IV. Staff interviews LPN #2 was interviewed on 8/20/24 at 1:06 p.m. LPN #2 said a RN, NP or a physician should complete an assessment of the resident, prior to moving the resident from off the floor. She said during this assessment, they would be looking for fractures, head injuries, bleeding, abnormalities in range of motion and the resident's consciousness. She said when a resident fell , during the next day's morning meeting, the fall would be discussed. She said Resident #3's mattress had slid off the frame and dycem ( a non-slip material used to help stabilize objects, hold objects firmly in place, or to provide a better grip) was placed on the bed. She said the resident removed the dycem and threw it in the trash can. She said clips were placed on the bed to keep it from moving. LPN #3 was interviewed on 8/20/24 at 1:30 p.m. LPN #3 said a resident should be assessed by a RN, NP or a physician before they were moved off the floor. She said an RN would do an assessment because the LPN could not do the assessment prior to moving the resident off the floor. She said staff would be assessing the resident for any head injuries, bleeding, fractures, skin tears, bruises, lacerations, cognitive deficit, range of motion concerns and pupil size. LPN #1 was interviewed on 8/20/24 at 1:50 p.m. LPN #1 said a RN, NP or a physician should assess a resident after an unwitnessed fall, prior to moving them from off the floor. She said during the assessment, they would be looking for any signs of a concussion, fractures, bleeding, range of motion problems, if the resident was alert/oriented and any possible head injuries. She said they were also looking for any changes in the resident's baseline (normality). The NHA and the director of nursing (DON) were interviewed on 8/20/24 at 3:20 p.m. The NHA said, for Resident #9, there were no RN, NP or physician assessments for the resident, prior to moving the resident from off the floor, for the unwitnessed fall in her room on 5/1/24. The DON said that a RN, NP or physician should perform an assessment for all unwitnessed falls, prior to moving the resident from off the floor. She said a fall was a resident unintentionally moving from one plane (position in space relative to the ground) to another plane. The DON said the assessment should include range of motion, skin assessment, vital signs and neurological assessments. She said the outcomes from a lack of an assessment could be any type of injury to the resident, fractures, orthostatic hypertension, low blood pressure, bleeding, skin tears, cognitive changes, altered mental status and aberrant range of motion. The NHA and the DON were interviewed together a second time on 8/20/24 at 4:20 p.m. The NHA said Resident #3 reported the two falls from the bed were due to the mattress issues. The resident's bed was locked and in the lowest position at the time of the two falls. The NHA said after the two falls from the bed, a new mattress was placed on her bed and anchor clips were placed on the bed to prevent it from sliding. The NHA said after the second fall from the bed, a dycem mat was placed under the mattress. He said the resident removed the dycem and placed it in the trash can. The NHA and the DON both said there were no RN, NP or physician assessments for Resident #3, prior to moving the resident from off the floor, for the unwitnessed falls on 3/16/24, 3/18/24 and 3/23/24.

Based on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in one of five medication carts and one of three medication storage rooms. Specifically, the facility failed to ensure: -Medications were labeled with the date opened; and, -Expired and discontinued medications were removed from the medication cart and storage room in a timely manner. Findings include: I. Facility policy and procedure The Storage of Drugs and Biologicals Policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:32 a.m. The policy read in pertinent part, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. II. Professional references According to the manufacturer [NAME] Lilly and Company, Humalog U-100 Insulin (February 2024), retrieved on [DATE] from https://www.humalog.com/u100, Opened Humalog vials, prefilled pens, and cartridges must be thrown away 28 days after first use, even if they still contain insulin. III. Observations and interviews On [DATE] at 7:35 a.m., the Red Cloud unit medication cart was observed with licensed practical nurse (LPN) #3. The following items were found: -A used Albuterol HFA inhaler was not labeled with the date it was opened; -A used QVAR Redihaler inhaler was not labeled with the date it was opened; and, -A used Humalog U-100 insulin Kwik Pen with a date opened label of [DATE]. -The Humalog insulin pen should have been discarded on [DATE], 28 days after opening. LPN #3 said the inhalers should be discarded because they were not labeled with the date they were opened. She said the insulin should have been discarded, however, she was not certain of the date it should have been discarded. On [DATE] at 9:31 a.m., the Frontier unit medication storage room was observed with registered nurse (RN) #2. The following item was found: Five vials of Hepatitis B Vaccine Recombinant Engerix B with an expiration date of [DATE]. RN #2 said the vaccines were expired and should be discarded. IV. Director of nursing (DON) interview The DON was interviewed on [DATE] at 11:06 a.m. The DON said nursing staff should label inhalers when opened. She said the insulin expired by [DATE]. The DON said she thought the insulin had been discontinued and should have been removed from the cart on the same day it was discontinued. She said expired vaccines should be discarded immediately upon expiration.

Based on record review and interviews, the facility failed to ensure quality of care and address needed communication for one (#45) of six residents reviewed out of 26 sample residents. Specifically, the facility failed to: -Ensure Resident #45's cardiac specialist was notified when the facility chose not to implement the specialist's recommended physician's orders; and, -Inform Resident #45 about medications ordered by a specialist that were not implemented by the facility. Findings include: I. Resident #45 status Resident #45, age 68, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included heart disease, cirrhosis of the liver, right leg amputation above the knee and peripheral vascular disease (reduced blood flow to limbs). The 12/23/23 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. He required substantial assistance with hygiene, mobility and transfer. II. Facility policies The Medication and Treatment Orders: Guiding Principles policy, undated, was provided by the nursing home administrator (NHA) on 2/26/24 at 10:20 a.m. It read in pertinent part, Physicians shall write medication orders that reflect known benefits and risks of medications in the facility's population. Medication orders will be accurate, timely, appropriate, and legible. The Physician Services Policy, revised February 2021, was provided by the director of nursing (DON) on 2/29/24 at 8:05 a.m. It read in pertinent part, The attending physician will determine the relevance of any recommended interventions from other disciplines. The physician is not obligated to accept these recommendations if he or she has clinically valid reasons for not doing so. -The policy did not address any required communication with residents, nursing staff, or specialists from another discipline if the recommended interventions were not accepted by the attending physician. II. Resident interview Resident #45 was interviewed on 2/26/24 at 3:47 p.m. He said he had a heart and vascular clinic appointment on 2/26/24 and learned he had not received medications ordered by the specialist two months ago. He said he had been to the emergency roiagnom on several occasions to drain excess fluid from his abdomen (paracentesis) and he was told by the heart and vascular specialist this might not have been necessary if he had taken the medication which was prescribed in December 2023. He said the head nurse told him there had been a communication problem and this was the reason he did not start the medications. III. Record review The MD Office Visit Communication form for the heart and vascular clinic visit, dated 12/27/23, was provided by the DON on 2/28/23 at 9:00 a.m. The new orders and signature section contained the following physician's orders from the heart and vascular physician assistant: -Begin 25 milligrams (mg) Toprol XL (medication which can be used to treat heart failure) daily; and, -Begin 12.5 mg Spironolactone (a diuretic medication used to treat heart failure) daily. Hold if systolic blood pressure is less than 90. -The orders were signed by registered nurse on (RN) #1 on with the word noted next to the signature and dated 12/27/23. -However, the orders were not entered into Resident #45's electronic medical record (EMR) A comprehensive review of Resident #45's physician orders revealed Spironolactone 12.5 mg one time a day was ordered on 1/4/24, however it was discontinued on 1/18/24. The MD Office Visit Communication form for the heart and vascular clinic visit on 2/26/24 was provided by the DON on 2/28/23 at 9:00 a.m. The notes from the physician section were signed by the heart and vascular physician (HVP) and contained the following documentation in pertinent part: Recent paracentesis for heart failure. Not sure why guideline directed medical therapy (GDMT) medications have been stopped. Need to escalate GDMT as tolerated. This will likely help with minimizing the need for paracentesis. The 2/26/24 visit new orders and signature section contained the following physician's orders from the HVP: Start Spironolactone 25 mg PO (by mouth) daily. Start Toprol XL 12.5 mg PO daily. After visit hospital summaries revealed Resident #45 had undergone paracentesis procedures on 12/29/23, 1/25/24 and 2/23/24 -Resident #45 began receiving Spironolactone and Toprol XL as ordered on 2/27/24 (during the survey), almost two months after the heart and vascular physician had originally ordered the medications. IV. Staff interviews The DON was interviewed on 2/27/24 at 3:11 p.m. The DON said Resident #45 told her there were medications he was not receiving as ordered. She said an MD Office Visit Communication form was returned with the resident to the facility on [DATE]. She said the nurse who received the heart and vascular specialist orders signed off both medications, however, she said the orders were not entered by the nurse in the resident's EMR. The DON said she considered the instructions from the specialist to be actual orders. She said the facility needed to work on its process for communication of new orders. The DON said she reviewed the orders with the nurse practitioner (NP) on 12/27/23 and the NP decided not to start the Spironolactone and Toprol XL medications until after the resident's paracentesis scheduled for 12/29/23. The DON said she did not communicate with the heart and vascular specialist regarding the NP's decision to wait to start the medications and she did not know if the NP consulted with him regarding non-implementation of the orders. The DON said she did not know why the Toprol XL was never started or why the Spironolactone medication was ordered from 1/4/24 to 1/18/24 and then discontinued. The DON said the NP preferred Lasix medication over Spironolactone. She said the provider group for the facility changed on 2/25/24. The DON was interviewed a second time on 2/27/23 at 3:52 p.m. The DON said RN #1 should not have noted the orders written by the heart and vascular specialist on 12/27/24 as they had not been entered in the EMR or initiated for administration. The facility's physician's assistant (PA) was interviewed on 2/27/24 at 4:00 p.m. The PA said the facility received a new form on 2/26/24 from the heart and vascular specialist with the same medications which were ordered on 12/27/23. The PA said she would document in her note if she did not agree with the specialist's treatment plan. She said she was happy the facility was starting Spironolactone as the new medication could decrease Resident #45's frequency of paracentesis. The NP was interviewed on 2/28/24 at 11:24 a.m. The NP said she did not start the Spironolactone and Toprol XL as ordered on 12/27/23 by the heart and vascular specialist because of the resident's trend of low blood pressures. She said she did not know if the heart and vascular specialist was aware the medication was not started. The pharmacist consultant (PC) was interviewed on 2/28/24 at 11:34 am. She said the resident did not have orders for Spironolactone prior to 1/4/24. She said the pharmacy did not have orders for both Spironolactone and Toprol XL until 2/26/24. She said Spironolactone could help with reduction of fluid in the abdomen. She said Toprol XL would not be as helpful for fluid reduction, but would be indicated for the resident's heart condition. The facility's physician (PH) was interviewed on 2/28/24 at 12:48 p.m. The PH said Resident #45 had advanced heart disease and cirrhosis of the liver. She said if she disagreed with the specialist, her process was to reach out to the specialist directly. (This physician began working at the facility on 2/25/24). She said Resident #45 was medically fragile with a lot of chronic disease. She said it was important to communicate why medication should not be started. She said any order in the facility had to be signed by a provider at the facility. The PH said the communication sheet from the specialist was a recommendation and when the facility provider cosigned, it became an order. RN #1 was interviewed on 2/28/24 at 3:53 p.m. RN #1 said she signed the order at the bottom of the MD Office Visit Communication form and she said it meant she had seen the orders. She said she did not enter the orders into the electronic record as the NP wanted to wait to start the medications. She said she did not document this in Resident #45's record. The heart and vascular physician (HVP) was interviewed on 2/28/24 at 4:41 p.m. The HVP said the facility did not communicate with him when Toprol XL was not started or about the delayed start and then discontinuation of Spironolactone. He said two months of treatment was lost. He said he would expect the facility to call if there was concern regarding Resident #45's blood pressure being too low with the addition of Spironolactone and Toprol XL, as the parameters for low blood pressure was different for a population who were not as sick as Resident #45. The HVP said he hoped the facility provider would have communicated immediately with him if they were not going to follow his recommendations. The DON was interviewed again on 2/29/24 at 10:11 a.m. The DON said she asked the NP if she wanted to talk with the heart and vascular specialist (ordering physician) and the NP declined. She said there was a lack of collaboration between the primary care provider and the heart and vascular specialist. She said she would expect the nurse to document in the record if orders were not implemented. She said the facility process needed to be improved to provide better communication. Licensed practical nurse (LPN) #5 was interviewed on 2/29/24 at 1:33 p.m. LPN #5 said she would discuss with the DON if orders were not implemented by the facility physician. She said she would document in the resident's chart if the physician did not implement a specialist's orders. LPN #2 was interviewed on 2/29/24 at 1:47 p.m. LPN #2 said she discussed with the unit manager if there were order changes. She said she signed noted at the bottom of the orders, which means the orders have been completed and entered into the record. She said she would not sign the form if the orders were not implemented. She said she would check with the unit coordinator to see if she needed to document in the record if orders were not implemented. The NHA was interviewed on 2/29/24 at 2:07 p.m. The NHA said he expected the resident to be notified by nursing staff if the ordered medications were not implemented by the facility provider. He said he would expect the facility provider to discuss this with the resident. LPN #1 and the DON were interviewed together on 2/29/24 at 3:00 p.m. Both LPN #1 and the DON said RN #1 should have notified the resident if he was not going to start taking medications prescribed by the specialist. V. Facility follow-up On 2/29/24 at 3:55 p.m., the DON provided the following documentation: Quality Assurance Orders Action Plan: Identified areas for improvement: -Physician Services Collaboration related to new orders. -When a new order is received from an alternate physician other than the attending physician collaboration is to occur between the two providers and nursing. -Communicate these changes with resident and/or family. Plan: -Education with new in-house providers related to collaboration with outside physicians. -Education with nurse's related to new orders received from outside providers. Nurses will also be educated on documenting follow up related to new order from outside providers. -MD communication forms will be reviewed and audited by DON and clinical coordinator. -The facility did not implement the action plan until the concern for orders not being implemented was brought to their attention during the survey.

Based on observations, record review and interviews, the facility failed to ensure effective infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Specifically, the facility failed to ensure: -Residents were offered and assisted with hand hygiene prior to meals; and -Staff were following guidelines for proper personal protective equipment (PPE) use. Findings include: I. Facility policy The Novel Coronavirus Prevention and Response policy was provided by the interim nursing home administrator (INHA) on 6/16/2020 at 6:07 p.m. The policy read in part: Interventions to prevent the spread of respiratory germs within the facility: - Support hand hygiene and respiratory/cough etiquette by residents, visitors and employees by making sure tissues, soap, paper towels and alcohol-based hand rubs are available. - Educate staff on proper use of personal protective equipment and application of standard, contact, droplet and airborne precautions, including eye protection. II. Status of COVID-19 in the facility The director of nursing (DON) was interviewed on 6/15/2020 at 10:28 a.m. She reported that total resident census was 38, and there were no COVID-19 positive residents, however three residents were on droplet precautions isolation. She said there was no staff ill with COVID-19. She said since the pandemic started 10 residents passed away from COVID-19 in the facility. III. Failure to offer and assist with resident hand hygiene A. Observations On 6/15/2020 at 12:15 p.m. an observation of lunch meal service revealed the residents were not offered hand hygiene before food was served. Most residents were observed using their hands to consume the meal. On 6/15/2020 at 12:14 p.m., two residents were served meals in the assisted dining room. The residents were not offered hand hygiene and both residents ate their food with their hands. On 6/15/2020 during lunch service, multiple staff members were observed delivering lunch meal trays to residents, none of the residents were offered hand hygiene prior to their meal. On 6/16/2020 at 5:45 p.m., multiple staff members were observed to pass meal trays. None of the residents were offered hand hygiene before they ate their meals. On 6/16/2020 at 5:35 p.m. an observation of supper meal service revealed the staff did not offer hand hygiene to residents before food was served. Most residents were observed using their hands to consume the meal. B. Interviews Resident #3 was interviewed on 6/15/2020 at 12:27 p.m. She said the staff did not offer her any hand hygiene prior to her meals. Resident #1 was interviewed on 6/15/2020 at 12:40 p.m. She said the staff did not offer her hand washing or hand sanitizing before the meal was served. Resident #2 was interviewed on 6/15/2020 at 12:45 p.m. He said the staff did not offer him assistance with hand washing or hand sanitizing before the meal was served. He said, Once in a while throughout the day I wheel myself to the hallway and use the hand sanitizer dispenser that is on the wall across from my room. He said, They don't like when I leave my room but I don't have the hand sanitizer and no one has offered to help me wash my hands in very long time. He said he was unable to use the sink in his bathroom to wash his hands independently. Residents #1 and #2 were interviewed again on 6/16/2020 at 5:50 p.m. They both said the staff did not offer hand washing or hand sanitizer before the supper meal. The DON was interviewed on 6/16/2020 at 6:20 p.m. She said the staff was trained and reminded to use hand sanitizer or offer hand washing to all residents prior to meal service. She said her expectation was residents' hands were washed before and after meals, after bathroom use or pericare was done, and as needed. She said the staff would receive refresher training on the necessity of offering hand washing and hand sanitizing to residents before meals. IV. Failure to properly wear PPE A. Professional reference The Centers for Disease Control (CDC) Key Strategies to Prepare for Coronavirus COVID-19 in Long Term Care Facilities, dated April 2020, read in pertinent part: If COVID-19 was identified in the facility, have health care providers (HCP) wear all recommended PPE for care of all residents (regardless of symptoms) on the affected unit (or facility-wide depending on the situation). This includes: an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and gown. HCP should be trained on PPE use including putting it on and taking it off. This approach is recommended because of the high risk of unrecognized infection among residents. Recent experience suggests that a substantial proportion of residents could have COVID-19 without reporting symptoms or before symptoms develop. B. Observations and interviews A physician assistant (PA) was observed on 6/15/2020 at 11:15 a.m. to enter a droplet precaution isolation room [ROOM NUMBER] without full PPE gear. After she exited the room she said she only delivered water to the resident and did not need to wear full PPE (gown, gloves, mask and eye protection). Registered nurse (RN) #1 was interviewed on 6/15/2020 at 11:25 a.m. He said full PPE gear worn in a droplet precautions isolation room included a gown, gloves, eye protection and a mask. He said no staff should enter the room without full PPE. RN #2 was interviewed on 6/16/2020 at 3:45 p.m., she said a gown, gloves, surgical mask, and eye protection was worn in an isolation room. She said all staff members who entered the room wore the PPE to prevent the spread of infection. Upon entrance to the facility, on 6/15/2020 at 10:00 a.m., the director of nursing (DON) was observed with a KN95 mask worn upside down and resting below her nose. On 6/15/2020 at 12:19 p.m. certified nurse aide (CNA) #1 was observed delivering lunch room trays to residents. She had eye protection on and her N95 mask was worn upside down. At 12:51 p.m. she delivered a lunch meal tray to the resident in a room on isolation droplet precautions. She donned her PPE in the following order: gloves, then gown, then shoe covers, then hair cover, then a second pair of gloves. Her facemask was still upside down and she did not perform CDC recommended hand hygiene while donning her PPE. CNAs #2 and #3 were observed on 6/16/2020 at 4:41 p.m. entering the droplet precautions isolation room. They donned PPE in the following order: they put on their gown, then N95 mask, then eye protection, then two pairs of gloves. They did not perform hand hygiene at any time during the donning process. CNAs #2 and #3 were observed again on 6/16/2020 at 5:35 p.m. entering the droplet precautions isolation room. They donned PPE in the following order: they put on their gown first, then shoe covers, then hair cover, then the N95 mask and gloves. They did not perform hand hygiene before putting on their gloves. C. Staff interviews CNA #2 was interviewed on 6/16/2020 at 4:53 p.m. She said she wore two pairs of gloves because she wanted to have an extra pair of gloves just in case she needed to take a pair off while in the room. She said she did receive training on how to properly wear PPE. The DON was interviewed on 6/16/2020 at 6:23 p.m. She said staff should put their PPE in order from top to bottom. She said they should perform hand hygiene, then put on their mask, then eye protection, then gown, then perform hand hygiene again and put on one pair of gloves. She said the staff should not double glove. She said the last PPE training for all staff was conducted about six weeks ago. She said she will provide another training to ensure staff were following proper donning and doffing of the PPE.

Based on observations, resident and staff interviews and record review the facility failed to ensure nine (#1, #2, #3, #4, #5, #6, #7, #8 and #9) of nine sampled residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. -This failure created the likelihood of immediate and serious adverse outcome for Resident #2. -This failure compromised the nutritional status of Residents #1, #3, #4, #5, #6, #7, #8 and #9 who experienced weight loss, at a significant level. Specifically: ASPIRATION AND CHOKING RISK -Resident #2, severely cognitively impaired, had a long standing and significant history of dysphagia. In September 2019, speech therapy (ST) assessed the resident at severe risk of aspiration and choking, and recommended nectar thick liquids (NTL). Although the resident declined the recommendation, documented in a dietary waiver dated 9/10/19, the facility failed to take steps, beyond the waiver, to promote the resident's safe and adequate fluid intake. Specifically, ST recommendations (close supervision, upright at 90 degrees during and after meals, head of bed at 45 degrees at all times, alternating small bites/sips), were not incorporated into the resident's care plan and not implemented by staff. Further, when ST notes documented the resident's acceptance of NTL beginning the first week in April 2020, which lessened his risk of aspiration and choking, the facility failed to communicate this change by obtaining an order for [REDACTED].#2 experiencing aspiration, aspiration pneumonia and severe physical decline. -Resident #1 failed to receive supervision while eating after choosing to go against diet texture recommendations and eat regular texture food instead of the recommended puree texture based on [MEDICAL CONDITION] complications and a history of an emergent hospitalization related to eating regular texture food and food stuck in his esophagus. Lack of staff supervision created the potential for compromised nutritional status - aspiration, choking and physical decline. WEIGHT LOSS -Resident #2, who was severely cognitively impaired, required assistance with eating, and was at risk for aspiration and choking (see above), failed to receive adequate and timely interventions to promote his nutritional status (weight maintenance and/or weight gain). He experienced a severe weight loss in one month (23.2#/12.7%) -Resident #3, who was severely cognitively impaired and required extensive assistance with eating, failed to receive adequate and timely interventions to promote his nutritional status (weight maintenance and/or weight gain) after weight loss was identified and the resident began eating in his room, instead of the restorative dining room. He experienced a severe weight loss in one month (11.6#/ 7%). -Residents #4, #5, #6, #7, #8 and #9, identified with weight loss, failed to receive timely interventions to assist with weight maintenance and/or weight gain. All six residents experienced significant weight loss. Findings include: I. IMMEDIATE JEOPARDY A. Findings of immediate jeopardy Resident #2, severely cognitively impaired, had a long standing and significant history of dysphagia. In September 2019, speech therapy (ST) assessed the resident at severe risk of aspiration and choking, and recommended nectar thick liquids (NTL). Although the resident declined the recommendation, documented in a dietary waiver dated 9/10/19, the facility failed to take steps, beyond the waiver, to promote the resident's safe and adequate fluid intake. Specifically, ST recommendations (close supervision, upright at 90 degrees during and after meals, head of bed at 45 degrees at all times, and alternating small bites/sips), were not incorporated into the resident's care plan and not implemented by staff. Further, when ST notes documented the resident's acceptance of NTL beginning the first week in April 2020, which lessened his risk of aspiration and choking, the facility failed to communicate this change by obtaining an order for [REDACTED].#2 experiencing aspiration, aspiration pneumonia and severe physical decline. On 4/30/2020 7:06 p.m., the nursing home administrator (NHA), unit manager, and director of clinical operations (DCO) were notified of the immediate jeopardy situation created by the facility's failure to take steps, beyond the dietary waiver, to promote the Resident #2's safe and adequate nutritional intake. B. Facility plan to remove immediate jeopardy On 5/1/2020 at 1:04 p.m., the facility submitted a plan to abate the immediate jeopardy. The abatement plan read: Alleged Deficient Practice Staff did not monitor or provide cueing for the resident # 8219 (Resident #2) to eat and drink according to speech therapy directions for his dysphagia. Resident #8219 has order for Mechanical Soft texture and SLP has recommended nectar thick liquids. Power of Attorney is adamant of honoring resident's rights and has signed a waiver to allow thin liquids. Corrective Action On 4/30/2020 all staff providing care to resident #8219 were educated on the following: Food and liquids will not be left at bedside. The licensed nurse will offer food and liquids every two hours while awake. When resident is provided food or liquids the licensed nurse will assist and monitor. Resident will be encouraged to sit in an upright position when eating and drinking. Hydration and food log will be implemented to monitor intake. Certified nursing assistants will notify licensed nurse when resident is requesting food or liquids. Resident will continue to receive a mechanical soft diet and thin liquids per Power of Attorneys request and waiver in place. Identification of Others All residents at the facility have the potential of being affected by this alleged deficient practice. The Director of Nursing and Speech therapist will conduct an audit completed by 5/4/2020 on all residents that are currently receiving a modified diet to ensure those residents are receiving frequent monitoring and supervision when eating. The Speech Therapist will screen all residents receiving a(n) altered/modified diet. Systemic Changes Speech therapist provided dysphagia management education including; dysphagia definitions, Textures, adaptive equipment, strategies, feeding, oral care, waivers, and SLP role. This education was provided to clinical staff on 5/1/2020. Resident(s) that are receiving an altered/modified diet and are at risk of choking and/or aspirating requiring assistance with eating and drinking will receive the assistance needed. Monitoring The DON and/or designee will conduct an audit 5x/week for 90 days in order to ensure residents with altered/modified diets and are at risk for choking and/or aspirating are receiving monitoring and/or assistance during food and fluid intake. The DON/designee will report to QA Committee any identified issues. The DON/designee will be responsible for any follow up recommendations made by the QA Committee The above plan was accepted and the immediate jeopardy situation abated at 1:04 p.m. on 5/1/2020, based on interviews obtained with staff, indicating they had been informed of Resident #2's dietary restrictions. However, observations, record review and interviews revealed deficient practice remained at H level, a pattern of actual harm. II. RESIDENTS AT ASPIRATION AND CHOKING RISK A. Resident #2 Resident #2, [AGE] years old, admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The 4/6/2020 minimum data set (MDS) documented the resident was severely cognitively impaired and was unable to complete the brief interview for mental status. The assessment revealed he had short and long-term memory problems and decision-making was severely impaired. He required extensive assistance with all activities of daily living (ADL) and supervision with eating. The swallowing/nutritional status MDS dated [DATE], documented the resident would cough or choke during meals or when swallowing medication and required mechanically altered diet which required a change in texture of food or liquids. 1. Record review revealed the facility knew of the resident's need for supervision and assistance at meals to prevent aspiration and choking, well before the 4/6/2020 swallow/nutritional status MDS above. Although the most current dietary profile dated 12/16/19, after his readmission from the hospital for aspiration pneumonia, documented the resident was alert and did not have chewing or swallowing problems, a 9/10/19 speech evaluation and a subsequent evaluation 4/1/2020 indicated otherwise. a. The evaluation dated 9/10/19 documented the resident had long-standing dysphagia and swallowing had become worse. The evaluation read: -Patient had modified [MEDICATION NAME] swallow studies in the hospital as recently 12/2018. At that time it was recommended the patient consume pureed food and nectar thick liquid. Patient refused recommendation and signed a waiver to continue regular textures and thin liquids. -PLOF (prior level of function): nectar thick liquids, and severe swallowing abilities. -Assessment summary: Patient as severe risk of aspiration and choking; ST eval(uation) only as patient wishes to remain on regular thin liquids. Patient may be offered nectar thick, waiver in place for regular thick liquids. POA (power of attorney) provided extensive education regarding risks and benefits of consuming regular diet vs benefits of following recommended diet. -Risk factors: Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient is a risk for aspiration, malnutrition, pneumonia, weight loss, dehydration and further decline function. -Recommendations: Solids=Puree Consistencies, Liquids=nectar thick liquids (NTL), close supervision, upright at 90 degrees, small bites/sips, alternate bites of solids with sips of liquieds. Upright for at least 30 minutes after meals, HOB (head of bed) at least 45 degrees at all times. Patient does not follow recommendations. b. A 4/1/2020 speech evaluation documented the resident had a recent change in medical condition and increased difficulty swallowing. The evaluation read: -Assessment summary: Patient with moderate to severe oropharyngeal dysphagia (difficulty initiating a swallow). Recommend pureed, nectar thick liquids. Decreased functional activity tolerance, requires frequent breaks due to medical condition. -Risk factors: Aspiration. -Recommendations: Solids=Puree consistencies, Liquids = nectar thick liquids, close supervision. Upright at 90 degrees, small bites/sips. Patient refuses recommendations of nectar and pureed. Agreeable to naturally soft. Diet order switched to mechanical soft, thin liquids. Subsequent ST encounter notes 4/1 and 4/2 read the resident continued to refuse NTL, despite risk of aspiration and cough with thin liquids by cup. 2. Resident #2 and facility response to speech evaluations and recommendations Resident #2, through his power of attorney (POA), declined the ST recommendations in a dietary waiver, dated the same day as the 9/10/19 speech evaluation. The waiver read a pureed meal with nectar thick liquids had been recommended because of the resident's frequent coughing, near choking at meals. It further read, I understand that eating foods of a texture that are not recommended by the doctor and speech-language pathologist could result in choking, aspiration pneumonia and/or death. Comments on the form read, may offer nectar thickened liquids, pureed. If (patient) declines, honor his wishes. 3. Although the resident declined the speech recommendation for NTL as set forth in the 9/10/19 dietary waiver, record review and interview revealed the facility failed to take steps, beyond the waiver, to promote the resident's safe and adequate fluid intake. a. Failure to provide Resident #2 close supervision at mealtime. Interview with the nursing home administrator (NHA) on 5/1/2020 at approximately 10:00 a.m., revealed that since the COVID-19 pandemic (in March when communal dining was restricted), Resident #2 has eaten his meals in his room. The NHA said before that, the resident ate in the restorative dining room; there a nurse supervised the resident. The 4/6/2020 MDS assessment read Resident #2 required supervision with eating (see above), and the 4/6/2020 MDS triggered care plan updates that referenced the resident's risk for fluid deficit related to thickened fluids and his risk for aspiration pneumonia and/or choking. However, neither care plan addressed the resident's need for close supervision at mealtime as recommended by the ST even though, currently, he was eating his meals in his room rather than under nursing supervision in the restorative dining room. Specifically: -The care plan revised 4/6/2020 that documented the resident was at risk for fluid deficit related to thickened fluids read, (R)esident adamantly declines thickened fluids, family aware and waiver has been signed. The goal was for the risk of fluid deficits to be minimized with interventions through review date. Interventions included document episodes of diarrhea and emesis, fluids at bedside if not contraindicated, offer fluids at meals and at medication pass, provide appropriate fluid consistenc(y) (undefined) and refer to speech therapist (ST) if indicated. -The care plan revised on 4/6/2020 that documented the resident was at risk for aspiration pneumonia and/or chocking due to making the choice of not following recommendations (in regards to diet texture/fluid consistency) by facility staff read, the goal was for the risk of aspiration/choking will be minimized with interventions. Interventions included to honor the residents choice, monitor lungs and vital signs as needed, provide resident and family education regarding risk factors, refer to ST as needed and review risk vs benefit statements quarterly and as needed. Record review and interviews confirmed both Resident #2's need for, yet staff's failure to provide, close supervision during meals for the resident's safety and to ensure adequate intake. -A 4/13/2020 physician note read the physician saw the resident on 4/13/2020 for [MEDICAL CONDITION], dehydration and a (recent) emergency room (ER) visit. The note read, The patient does have what appears to be fairly significant dysphagia. He is on a modified diet with pureed texture and nectar thick liquids. Continue to monitor closely for aspiration. He appears to be an ongoing aspiration risk given his history of [MEDICAL CONDITION](stroke). It further read under hospital course: Episodes where he has difficulty with swallowing and there is concern that he will have an aspiration event. He has had pneumonia in the past, presumably related to this. The director of rehabilitation (DOR), interviewed by phone on 4/30/2020 at 4:29 p.m., said her team had recently gotten involved with Resident #2 because he had increased difficulty with swallowing and the resident was experiencing weight loss. She said he should have close supervision while eating because he does have difficulty, coughs a lot and staff can encourage him to eat. She said Resident #2 was definitely at risk of aspiration pneumonia and death if he continues to eat what he wants. She said he is at more risk because of his prior [MEDICAL CONDITION]. Certified nurse aide (CNA) #5, interviewed on 4/30/2020 at 2:45 p.m. said Resident #2 required minimal assistance with meals. She said staff would cut up his food and cue him when they walked by his room, but said no one stays in there (his room) when he eats. The ST, interviewed on 5/1/2020 at approximately 3:00 p.m., said she met with Resident #2 and completed a speech evaluation. She said the resident should receive encouragement at mealtime and he required frequent checks; she said one to one supervision would be the best. She further stated his actual intake of food and drink should be observed and any signs and symptoms of difficulty (coughing, gurgling noise and spitting out food) should be reported. b. Failure to provide cueing to alternate small bites/sips, upright positioning at and during meals, head of bed at 45 degrees at all times as recommended by the ST. See care plan revisions above; none of the ST recommendations were addressed on Resident #2's care plan. While the CNA kardex read to monitor for and report any difficulty chewing/swallowing, or signs and symptoms of aspiration, and to report ST services as needed, the kardex did not address the resident's specific need for monitoring at mealtime. CNA documentation for April 2020 read staff did not provide the resident oversight during meals 35 times during the month out of 90 opportunities. Resident #2 was observed on 4/30/2020 at approximately 7:45 p.m. He was lying flat in bed, not at the recommended 45 degrees, and his overbed table was approximately 6 inches from the side of the bed. c. Failure to ensure the resident received NTL once he started accepting NTL in April 2020 to reduce his risk of aspiration. ST encounter notes after 4/2/2020 indicated Resident #2 had become less resistant to NTL. -A note 4/7/2020 read, Patient consumed sips of NTL, improved responsibility to cues for single sips, no overt s/sx (signs/symptoms) dysphagia. Therapist thinned out NTL to slightly thick pt (patient) with delayed min-mod cough 2/2 and trials discontinued. -A note 4/15/2020 read, Patient drinks 8 oz (ounces) of NTL with no coughing. -All notes from 4/3/2020 through 4/29/2020, except the notes from 4/13/2020 and 4/19/2020, documented oral intake for current liquids were NTL. In an interview on 4/30/2020 at 4:29 p.m. the DOR said Resident #2 was currently on NTL and mechanical soft foods because he will do better with this texture; it was the safest texture. In an interview on 5/1/2020 at 3:00 p.m., the ST said she had the resident trial the NTL and the resident tolerated it well. She said when she trialed thin liquids, thin was not okay, (the resident had) immediate and delayed coughing. Yet, there was a lack of communication, order, or evidence staff consistently provided and/or promoted the resident's intake of NTL. Specifically: -CNA #5, in her interview on 4/30/2020 at 2:45 p.m. (see above) said Resident #2 received regular textured food and regular liquids, nothing thickened -Record review revealed, and interview with licensed practical nurse (LPN) #1 on 4/30/2020 at 5:37 p.m. confirmed, Resident #2 did not have an order to receive NTL. -Review of Resident #2's waiver revealed it read that staff may offer NTL, and if the resident declined, to honor his wishes; however, there was no directive on Resident #2's care plan or CNA kardex for staff to start with an offer of NTL, as means to promote NTL and safe fluid intake. -Finally, observations of Resident #2's room on 4/30/2020 at 7:45 p.m. revealed the following liquids on his overbed table: a water pitcher, red punch, and a cup of coffee covered with foil. None of the drinks were NTL. 4. Staff interviews confirmed the facility failed to take steps, beyond the waiver, to promote the resident's safe and adequate nutritional fluid intake. The DOR, in her interview on 4/30/2020 at 4:29 p.m. stated at the NHA's request, she had conducted education with hospitality aides and nursing staff recently; she thought within the last ten days. However, she said nothing was written down, and she had not taken steps to ensure the education was understood and implemented. CNA #2, interviewed on 5/1/2020 at 9:20 a.m. (after immediate jeopardy had been called), said she had heard this morning that the resident needed puree foods and that she was not to feed him, rather the nurse would assist him. The ST, in her interview on 5/1/2020 at 9:05 a.m. (after immediate jeopardy had been called), said the DOR had asked her to go to the facility to educate staff about Resident #2. The director of clinical operations (DCO), NHA and the ST were interviewed together on 5/1/2020 at 10:29 a.m. The DCO said, if the resident had a [DIAGNOSES REDACTED].? (However, the ST in an interview later the same day at 3:00 p.m. said not all aspiration is silent and described the seven levels of aspiration. She said there were only two levels that were considered silent; all the other levels involved coughing.) The DCO also questioned, whether with all of the changes related to COVID-19 and residents eating in their rooms, staff walking down the hall was not supervision enough. The DCO and the ST agreed, however, the resident required supervision, but stated the level of supervision was not defined. 5. Steps taken after abatement of the immediate jeopardy On 5/6/2020 at 12:17 p.m., the Director of Nursing (DON) provided a copy of the education she had completed on 5/5/2020 (five days after the immediate jeopardy was called) which documented Please be aware that the 2 residents (#1 and #2) who have waivers in place must be monitored at every meal. And documented on. There is an order in place that needs to be documented on every meal without fail. They need to be monitored by a LN (licensed nurse) and not a CNA for each meal. The DON agreed the education did not specify which nurses should conduct the monitoring or identify who the two residents were. The in-service training report dated 5/4/2020 at 8:15 a.m. completed by the ST documented for Resident #2, recommendation/approaches included: mechanical soft/thin per waiver and family request; recommend soft moist foods, add moisture to dryer foods and cut food bite size. Check patient frequently during meals and encourage him to eat/drink. Report/document and signs of difficulty swallowing and make sure patient is sitting upright for all PO (by mouth) intake. The goal was for the resident to increase safety and independence with least restrictive diet; decrease risk of malnutrition/dehydration. Signatures completed included an LPN, two CNAs and one hospitality aide. B. Resident #1 Resident #1, age 63, admitted the facility on 7/31/19. According to the CPO, [DIAGNOSES REDACTED]. The 4/21/2020 MDS documented Resident #1 had severe cognitive impairment with a BIMS score of six out of 15. He required supervision with most ADLs including eating, and extensive assistance with toileting and personal hygiene. The swallowing/nutritional status MDS documented the resident had no difficulty when swallowing and did not have a mechanically altered diet. 1. Record review revealed the facility knew of Resident #1's need for supervision and assistance at meals to prevent aspiration and choking, based his edentulous status (without teeth) and his history of choosing to go against diet texture recommendations and triggering emergent hospitalization . A 12/17/19 SLP (speech language pathology) evaluation and plan of treatment documented the resident's medical factors included [MEDICAL CONDITION] dysphagia, aspiration and choking. The oral peripheral exam read the resident was edentulous. The bedside swallowing assessment revealed in pertinent part: -Solids-Regular - Moderate: Clinical s/s (signs/symptoms) dysphagia: patient can masticate (chew) some regular solids; dysphagia appears to be more [MEDICAL CONDITION], as patient was very recently sent out to hospital with impacted solids in his esophagus. -Solids-Mech(anical) Soft - Mild:: Clinical s/s dysphagia; patient has easier time masticating mechanical soft solids, however, recommendation is still for puree due to poor [MEDICAL CONDITION] motility (contracting of esophagus). -[MEDICAL CONDITION] Phase - [MEDICAL CONDITION]: Patient/medial record indicates: Resident recent sent out to hospital to remove impacted solids from esophagus; per nursing, this is the 2nd time in it year he was sent out to hospital for this in the past year. Recommend GI follow up. -Recommendations - Solids = Puree Consistencies, Supervision for oral intake= Close supervision, upright at 90 degrees, small bites. Alternate bites of foods with sips of liquids. Slow rate. Recommend follow up with GI due to [MEDICAL CONDITION] dismotility. 2. Resident #1 and facility response to SLP recommendations Resident #1 declined the SLP recommendations, signing a dietary waiver the same day as the 12/17/19 SLP evaluation. The waiver read the interdisciplinary team had recommended the resident to be on a pureed diet because of narrow esophagus, risk of choking. The resident signed he understood the risk but prefer to make my own food choices and wish to decline the diet consistency that was prescribed. The DOR also signed the document. Comments on the form read, patient continues to decline trials of pureed (even mechanical soft) wants to continue regular (texture). 3. Repeat episodes of [MEDICAL CONDITION] obstruction following execution of waiver and facility's failure to take sufficient steps, beyond the waiver, to promote the resident's safe and adequate nutritional intake. a. Documentation of [MEDICAL CONDITION] obstruction Progress notes on 1/8/2020 at 3:16 p.m. and 10:55 p.m. revealed the resident was unable to swallow, the MD (physician) was in facility and assessed resident, sending to emergency department (ED) for evaluation and treatment. He returned at 10:55 p.m. from the ED after having procedure to push food through esophagus. It was reported to this nurse from ED that res(ident) should be on clear liquid diet if not wearing dentures while eating. Review of the hospital reports dated 1/8/2020 revealed Resident #1 was seen because of inability to swallow his secretions since having lunch today. It further read the resident has a history of recurrent [MEDICAL CONDITION] food impactions related to the fact that he refuses to wear his dentures and yet continues to eat solid food. His last foreign body extraction was less than a month ago. Food was found in the middle third and lower third of the esophagus. The resident was advised the only safe alternative in the future, if he continues to refuse to wear his dentures, would be to stay on a liquid diet. Physician notes 4/16 and 4/22/2020 documented the resident's multiple episodes of [MEDICAL CONDITION] obstruction. The 4/22/2020 note read, On a pureed diet or to eat with his dentures. Notably, he did not have his dentures in place today. b. Facility failure The care plan revised 2/4/2020 documented the resident was edentulous (without teeth) and currently did not have dentures. Resident received his new dentures but doesn't like them. Resident states that he's been without teeth for so long it just feels more natural to him. The goal was for the resident to be able to chew food sufficiently to swallow through review date. Interventions included refer to dentist as needed. The care plan revised 2/4/2020 documented the resident was at nutritional risk related to reported history of weight loss and food insecurity and was on a regular diet with thin liquids. The goal was to minimize risk of significant weight changes with appropriate interventions through next review. Interventions included monitor for and report any difficulty chewing/swallowing or signs and symptoms of aspiration and report to speech therapy as needed. Neither care plan referenced the resident's episodes of [MEDICAL CONDITION] obstruction in order to alert staff of this risk for serious harm. Neither of the care plans addressed or defined the resident's need for close supervision, or addressed other SLP recommendations to remain upright at 90 degrees, and to take small bites, alternating food with sips of liquids. Moreover, although the resident might and had the right to reject it, per the SLP, hospital notes as well as his physician, he was to receive a puree diet for safety when he was not wearing dentures. This, too, was not noted on the care plans; rather, the care plan (see above) documented the resident was on a regular diet. Finally, the care plans failed to include strategies staff had found effective in getting the resident to comply with SLP recommendations and to wear his dentures, or addressed the resident's history of hoarding, his panic behavior toward food (see interviews below) and interventions to lessen these behaviors which could contribute to unsafe food intake. The lack of the above information on the resident's care plans created the potential that staff would not consistently implement effective measures to promote the resident's safe nutritional intake. 3. Resident observation and interview Resident #1, interviewed on 5/1/2020 at approximately 4:20 p.m., said he went to the hospital a few months ago because food was stuck in his throat but he learned a valuable lesson. The resident was in bed and his overbed table was positioned next to him. He said he was told him he needed to wear his dentures if he was going to eat regular food but said he did not like to wear his dentures and knew that he needed to be more careful in the future. 4. Staff interviews a. LPN #1, interviewed on 5/1/2020 at approximately 4:00 p.m., said Resident #1 eats fast and in last few months, he ate so fast he had a bolus (mass of substance) of food and was sent to the hospital so they could push it down. She said sometimes when he eats he will make himself throw up so food will dislodge. She said he required constant education and said she has seen the resident almost panic when he doesn't have food. She said when she works with him, she will encourage fluid and tell him to tuck in his chin. She said she was told, after the IJ had been called that she needed to watch him through the night because he could choke at any time. She said he does not receive constant supervision during meals. b. LPN #2, interviewed on 5/6/2020 at 11:31 a.m., Resident #1 would choose regular textured food and not puree food; although she said she was always aware that the resident required puree texture. She said she knew the resident would cough, had an inability to swallow or clear his throat and would sometimes vomit the food. She said she and the resident had many conversations and she thought he understood the risk of choosing regular texture food. LPN #2 said a ST evaluation recommended the resident receive frequent checks, and the ST said the resident would not be at risk for aspiration as long as he was monitored. She said that she provides frequent monitoring by placing her cart outside of his door and keeping an eye on him every five minutes. She agreed he could choke instantly and in less time than in five minutes. LPN #2 said on 5/5/2020 (after the facility was notified of the immediate jeopardy situation), she talked with the DON about putting an order in the Medication Administration Record [REDACTED]. She said she had been told there should be a progress note entered to document whether the resident was tolerating meals, if there were any issues while eating, and that education was provided to ensure the resident was eating and chewing slowly. LPN #2 said Resident #1 had a history of [REDACTED]. She said he had a history of [REDACTED]. She said that the CNAs knew when they went in his room to provide cares throughout the day they would notify her if the resident (TRUNCATED)

Based on observations, record review and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in two of two kitchens. Specifically, the facility failed to: -Dispose of expired foods; -Ensure foods were labeled, dated and covered during storage; -Ensure food was stored at the proper temperature; -Ensure the kitchen and food equipment was clean; -Prevent potential contamination; -Ensure proper thawing practice for frozen foods; and -Ensure proper food temperatures were taken for tray line service. Findings include: I. Facility policy and procedure The Food Preparation and Service policy, revised (MONTH) (YEAR), provided by the nursing home administrator (NHA) on [DATE] at 3:14 p.m., revealed Refrigerated foods must be stored below 41 degrees Fahrenheit (F) unless otherwise specified by law . Food and nutrition services staff shall wear hair restraints . so that hair does not contact food . Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness Gloves can become contaminated and/or soiled and must be changed between tasks . Thawing frozen food . submerging the item in cold running water . The danger zone for food temperatures is between 41 and 135 degrees F. The Sanitization policy, undated, provided by the NHA on [DATE] at 3:14 p.m. revealed All kitchens, kitchen areas and dining areas shall be kept clean .all utensils, counters, shelves and equipment shall be kept clean .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils. II. Expired foods The main kitchen was observed on [DATE] at 8:00 a.m. The walk-in refrigerator contained a half-gallon container of lowfat buttermilk with a manufacturer's date of [DATE]. The walk-in refrigerator was observed again on [DATE] at 9:35 a.m. with the following: -A half-gallon container of low fat buttermilk was dated with a manufacturer's date of [DATE]. The container was marked as received on ,[DATE]. (Two months past the manufacturer's date.) -Three five-pound containers of Ricotta cheese were dated with a manufacturer date of [DATE]. The containers were marked as received on ,[DATE]. (Over three months past the manufacturers date.) The certified dietary manager (CDM) was interviewed on [DATE] at 4:03 p.m. She said she looked through the food items for ordering purposes. She said she had not noticed the expired food items. She said she had not thought about it. She said the cooks should have been looking at the foods for expiration. She said she needed to make a better habit of looking at the food items for expiration. III. Labeling, dating and covering The main kitchen was observed on [DATE] at 8:00 a.m. The walk-in refrigerator had a small container of five large hot dogs. The container was not labeled or dated. The sandwich station refrigerator had the following: -A container of chicken fingers, undated and uncovered; -A container of beef stew, uncovered; -A container of cubed white meat, uncovered; and -Containers of rice, soup and shredded cheese, all uncovered. The sandwich station refrigerator was observed again on [DATE] at 9:27 a.m. with the following: -A large container of white shredded cheese, uncovered; -Containers of mushrooms and green peppers, uncovered; -A tall carton of liquid eggs, open and uncovered; -A container of breaded nuggets, unlabeled and uncovered; and -The top of the sandwich station contained shredded white cheese, sliced American cheese, ham slices, egg salad, potato salad and refried beans -- all uncovered. IV. Cold storage temperatures The main kitchen was observed on [DATE] at 8:10 a.m. The sandwich station refrigerator thermometer read 45 degrees F. The sandwich station refrigerator was observed again on [DATE] at 9:27 a.m. with a temperature of 45 degrees F. At 10:47 a.m., the temperature was approximately 44 degrees F. At 11:24 a.m., the temperature was ,[DATE] degrees F. The CDM was interviewed on [DATE] at 4:03 p.m. She said she had noticed the temperatures this morning. She said they had turned the temperature down and it had gotten to 42 degrees F. She said more adjustments were made. V. Cleanliness The main kitchen was observed on [DATE] at 9:25 a.m. The soap dispenser at the handwashing sink was dirty with spatter. The dish machine room had paint peeling from the walls and spatter all along the walls. The sandwich station refrigerator was observed on [DATE] at 9:27 a.m. It was dirty with food debris all along the bottom of the refrigerator and all along the internal shelving. The right side of the sandwich station refrigerator was dirty with spatter along the outside. -At 9:34 a.m., the wall behind the knife rack was observed as dirty along. One of the knives was dirty. The main kitchen was observed on [DATE] at 10:38 a.m. One of the red sanitizer buckets was stored on the floor with several dirty rags in the solution. The shelving to the right of the prep table was dirty along the shelves and the arms of the rack. A pie crust was stored on top of a container of donut glaze and had flour debris all over the crust. The large container of baking powder was dirty. -At 11:06 a.m., the rack of skillets were observed with visible debris along the outside of the skillets. Resident #30 was interviewed on [DATE] at 9:43 a.m. He said the silverware was not always clean. Resident #56 was interviewed on [DATE] at 8:19 a.m. She said the trays were filthy and her coffee mug stuck to the tray this morning. VI. Contamination The main kitchen was observed on [DATE] at 11:12 a.m. Cook #1 was observed wearing gloves. He touched the open trash can with his gloved hands. He then proceeded to pick up the cooked loaves of pork with the same gloves hands. He cut the pork using the same gloved hands on a yellow cutting board. At 11:15 a.m., the took the gloves off and washed his hands for a few seconds. He then put on a new pair of gloves. The CDM was interviewed on [DATE] at 4:03 p.m. She said she didn't think she had educated the staff on proper glove use. She said they had a list of the proper cutting board usage hanging on the wall. Review of the Prevent Cross Contamination guideline for cutting boards revealed the brown cutting board should have been used for cutting cooked meats. VII. Thawing practice The main kitchen was observed on [DATE] at 11:22 a.m. There was frozen chicken in one of the sinks of the three-pan sink. Water was running over a small portion of the chicken. The chicken was not fully submerged in the water. The CDM was interviewed on [DATE] at 4:03 p.m. She said she had not previously noticed any improper thawing practices. VIII. Tray line temperatures The main kitchen was observed on [DATE] at 11:30 a.m. Cook #1 was taking temperatures of the food items. He appeared to have difficulty reading the thermometer. For the brussels sprouts, the temperature was approximately 130 degrees F and the cook said it was 140 degrees F. For the mashed potatoes, the temperature was approximately 150 degrees F and the cook said it was 160 degrees F. The temperatures of the food on the sandwich station was as follows: -The potato salad was approximately 50 degrees F.; -The egg salad was approximately 42 degrees F.; -The tuna salad was approximately 42 degrees F; -Sliced ham was approximately 44 degrees F. Review of the Food Temperature Log for the main kitchen revealed the following: [DATE] at lunch: all the hot foods were documented as 160 degrees F except for the pureed vegetable which was documented as 120 degrees F. Review of the Food Temperature Log for Frontier kitchen revealed the following: [DATE] for dinner meal: all of the hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. ,[DATE]-[DATE] for dinner meals: all hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. ,[DATE]-[DATE] for dinner meals: all hot foods documented as 150 degrees F. and all cold foods documented as 40 degrees F. [DATE]: missing documentation; [DATE]- [DATE] for dinner meals: all hot foods, except the pureed meat, were documented as 150 degrees F. All of the cold foods documented as 40 degrees F. No variation in temperatures. The CDM was interviewed on [DATE] at 4:03 p.m. She said she had just ordered about 10 new thermometers. She said she had noticed some of the same temperatures documented for the food items. She said they did not have any logs when she first started. IX. Additional interviews The CDM was interviewed again on [DATE] at 4:03 p.m. She said the RD completed a monthly sanitation audit. She said that the infection control nurse also completed an audit related to infection control for the kitchen. She said he looked at the sinks, refrigerators and hair restraints. She said she tried to fix anything the RD identified during her inspections. She said she did not have her own audit tool.

Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to properly sanitize/disinfect scissors and other equipment (a flashlight and a permanent marker) used for multiple residents before and after providing wound care. Findings include: I. Facility policy and procedure The Infections-Clinical Protocol policy, revised (MONTH) (YEAR), provided by the director of nursing (DON) on 12/9/19 at 1:50 p.m., read in pertinent part: The physician or provider and staff will identify infection transmission risks and (in conjunction with the infection preventionist) will implement relevant precautions. The manufacturer's guidelines for the Micro-Kill plus disinfecting wipe, provided by the DON on 12/9/19 at 1:50 p.m., read in pertinent part: This product is not to be used as a terminal sterilant/high level disinfectant on any surface or instrument that is introduced directly into the human body, either into or in contact with the bloodstream or normally sterile areas of the body. Thoroughly wet pre-cleaned, hard, non-porous surface with a wipe, keep wet for two minutes, and allow to air dry. Use as many wipes as needed for the treated surface to remain wet for the entire contact time. You may use a wipe to pre-clean the surface to be disinfected, but thorough re-wiping with a fresh wipe is required for disinfection. II. Observations An observation of a wound VAC (vacuum-assisted closure of a wound) change on 12/9/19 at 11:08 a.m. with registered nurse (RN) #1 revealed the following: He gathered supplies from the top drawer of the treatment cart, that included a flashlight, a black permanent marker, and two pairs of scissors, (a black handled pair of bandage scissors, that had the word autoclave imprinted on the handle, and a metal pair of pointed scissors) that were lying loose in the top drawer with several other pairs of bandage scissors. He did not clean these items and placed the supplies on a paper barrier, and entered the resident's room, placing it on the resident's bed. He used the black handled bandage scissors to cut the tubing of the wound vac close to the connection on the resident's hip. He did not clean the scissors and placed them back on the paper barrier. Wearing gloves, he removed the soiled dressing material and the wound vac sponge from the wound bed. He did not change gloves and picked up the flashlight to view the wound bed, then placed it back on the paper barrier. He used a cotton tipped applicator to measure the wound by placing it into the wound bed several times, then laying it on a paper measuring strip, touching the tip of the applicator that had been in the wound. The wound measured: length 4.0 centimeters (cm) x width 5.7 cm x depth 2.9 cm. He used the same cotton tipped applicator to measure undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) at the five to seven o'clock position of 2.2 cm. Wearing the same gloves, he used the black permanent marker to write the measurements on the paper strip. At this point he changed gloves and opened the sealed package of wound vac supplies. He cut a long piece of plastic film with the bandage scissors and covered the entire wound and the skin across the resident's hip. He used the pointed metal scissors to cut out an opening over the wound bed. He then used the bandage scissors to cut a piece of black foam to fit into the wound. He placed the piece of foam into the wound, removed it to trim more off of it several times with the bandage scissors and placing it back into the wound each time. Wearing the same gloves, he then used the bandage scissors to cut strips of foam and plastic film to create a bridge across the resident's hip where the vacuum would be attached. He used the pointed scissors to snip a small opening in the film at the end of the bridge, and attached the tubing connector to the bridge to allow suction once the vacuum was turned on. He removed his gloves and opened a new vacuum drainage canister. When he tried to place it into the suction machine he dropped it on the floor. It rolled under the resident's bed. He retrieved it and placed it into the machine and turned it on. He placed the paper barrier, with the soiled supplies, on the resident's over-bed table. He donned gloves and exited the room, touching the door handle, and reentered the room wearing the same gloves and carrying two sanitizing wipes. He then wiped both pairs of scissors, the flashlight, and the marker with the same wipe and placed them back onto the paper barrier he used throughout the wound treatment process. He did not keep the items wet for the required two minute dwell time. He exited the room again, wearing gloves, touching the door handle, and returned with another wipe and wiped the wound vac machine and its case, using the same wipe. He did not keep the items wet for the two minute dwell time required by the manufacturer's guidelines. He removed his gloves and picked up the scissors, flashlight, and the marker from the paper barrier and placed them on top of the treatment cart, then back into the top drawer of the cart with the other scissors and supplies. He did not clean the resident's over-bed table after removing the supplies and the paper barrier. III. Interviews RN #1 was interviewed on 12/9/19 at 11:55 a.m. He said he had 12 residents with wounds that he provided treatments for. He said he had different scissors he used for different things and they were all kept loose together in the top drawer of the treatment cart. He said he used these scissors on all the residents for their wound treatments. He was unaware the black handled bandage scissors had the word autoclave imprinted on the handle. He acknowledged the facility did not have an autoclave machine to sterilize the scissors. He said he used the Micro Kill plus wipe to clean the scissors after use, because it was his understanding it killed everything and he was not aware of the two minute dwell time of the wipe. The DON was interviewed on 12/9/19 at 12:05 p.m. She acknowledged the potential for cross contamination by using the same scissors for multiple residents when doing wound care, especially if the scissors were labeled to be autoclaved. She acknowledged the facility did not have an autoclave machine to sterilize scissors. She said the Micro Kill plus wipe had a dwell time of two minutes, and items that were being cleaned had to remain wet that length of time. She said the nurses should follow manufacturer's guidelines. She said the wipe was not a good choice to clean scissors because it could not get into all areas of the scissor. She said it would be ideal for each resident to have their own supplies, and she would ask the facility central supply clerk to order disposable scissors for each resident who was receiving wound treatment. IV. Facility follow-up On 12/10/19 at 2:30 p.m. the DON said she had ordered enough pairs of scissors for each resident that was receiving wound care to eliminate the possibility of cross contamination from using the same scissors for multiple residents.

Based on observations, record review and interviews, the facility failed to provide food that was palatable, attractive, and appetizing for nine (#5, #6, #43, #52, #47, #56, #30, #8, and #29) out of 33 sample residents. Specifically, the facility failed to provide food that was not undercooked or overcooked, resulting in bland, runny, dry and/or tough foods for five residents representing resident council along with Resident #30, Resident #56, Resident #52, Resident #8 and Resident #29. Findings include: I. Facility policy and procedure The (YEAR) Dining Experience policy, undated, provided by the nursing home administrator (NHA) on 12/10/19 at 11:46 a.m., revealed Staff members will strive to enhance the resident's quality of life while serving meals that . are palatable to the resident. The 2019 Poached Egg recipe, undated, provided by the NHA on 12/9/19 at 3:14 p.m. revealed: .cook seven minutes to hard cook the eggs. [NAME]s and yolks should be completely set. II. Observations The main dining room was observed on 12/9/19 at 9:02 a.m. Two residents were observed to have received undercooked poached eggs. The whites of the eggs were runny, not fully cooked. III. Test tray Review of the test tray on 12/9/19 at 11:55 a.m. revealed the pork was dry, bland and tough. The pork was difficult to cut or chew. IV. Resident council interview Five members of the resident council (Residents #5, #6, #43, #52 and #47) were interviewed on 12/5/19 at 11:00 a.m. All five residents said the food was going downhill fast. They felt the food was bland and overcooked, especially the vegetables. Three residents (#5, #43 and #52) said they did not order the vegetables any longer because they would taste awful. All five residents said the meat was overcooked, tough, and hard to chew so they would not eat it. V. Record review and resident interviews Resident #30 was interviewed on 12/4/19 at 9:43 a.m. The 10/29/19 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. He said the eggs were undercooked. He said when he ordered the biscuits and gravy recently, the biscuits tasted frozen. Resident #30 was interviewed again on 12/9/19 at 9:01 a.m. He said he no longer ordered the eggs because they were always undercooked. Resident #56 was interviewed on 12/10/19 at 8:19 a.m. The 11/12/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. When asked about the food, she said I don't like it. She said the food was institutional and too salty. The meat was overcooked. She said she got the pork the day before and was unable to chew it. She said she received chicken (turkey) on a biscuit the night before without the biscuit because it was always raw. Resident #52 was interviewed on 12/10/19 at 10:11 a.m. The 11/7/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 14 out of 15. She said she sometimes did not care for the food at all. She said the meat was sometimes tough. She said they had green beans a lot which she liked, but needed more flavor. She said they did not season the food at the facility. Resident #8 was interviewed on 12/10/19 at 10:22 a.m. The 12/4/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. She said the food was alright. She said the meat was a little tough to chew, and she did not have teeth. Resident #29 was interviewed on 12/10/19 at 10:26 a.m. The 10/28/19 MDS assessment revealed the resident had intact cognition with a BIMS score of 15 out of 15. She said she would eat the food sometimes. She said she did not always know what the food was. She said she lost 15 pounds and was not trying to lose weight. VI. Staff interviews The certified dietary manager (CDM) was interviewed on 12/10/19 at 12:14 p.m. She said they had a dining committee meeting after resident council, once a month. She said they previously had complaints about the eggs being overcooked which may have resulted in them undercooking the eggs. She said the biscuits arrived precooked and were placed into the walk-in. She said they would run the biscuits through the toaster or microwave. She said she had heard of the residents stating the meat was tough and overcooked. She said they were trying different products to see what worked best. -At 12:41 p.m., she confirmed the biscuits were put through the toaster belt during service. She said she would get some additional condiments for the residents to help enhance flavor.

Based on record review and staff interviews, the facility failed to provide bed hold policy information for one (#73) of one resident reviewed for hospitalization out of 33 sample residents. Specifically, the facility failed to ensure Resident #73 was informed, in writing, of the bed hold policy when the resident transferred to the hospital from the facility. Findings include: I. Facility policy and procedure The Bed Hold policy, undated, was provided by the nursing home administrator (NHA) on 12/10/19 at 8:43 a.m. The policy revealed before a resident was transferred to a hospital or the resident went on therapeutic leave, the facility would provide written information to the resident and/or resident's representative that specified: the duration of the state bed-hold policy during which the resident was permitted to return and resume residency in the facility; the reserve bed payment policy in the state plan; and the facility's policies regarding the bed-hold period, which were consistent with the law permitting the resident to return. II. Resident status Resident #73, age 80, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/22/19 minimum data set (MDS) assessment indicated the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The resident required limited staff assistance with bed mobility, transfers, dressing and toileting. The resident was administered insulin injections daily and the insulin orders were changed twice in the seven day review period. III. Record review The nurse note, dated 12/3/19 at 3:09 a.m. by a registered nurse, revealed the resident had a blood glucose level of 73. The resident's skin was very white without any blue discoloration from inadequate oxygenation. The resident utilized three liters of oxygen per minute with a nasal cannula. The resident's respirations were labored and the resident had a harsh non-productive cough. The resident responded briefly to increased stimulation and presented with slurred speech. Physician orders [REDACTED]. The physician's orders [REDACTED]. The ambulance arrived at the facility and the resident was transferred to the emergency room with all appropriate paperwork. There was no documentation which showed the resident was verbally informed or received a written copy of the bed hold policy. A review of the resident's computerized clinical record failed to reveal the resident was notified by the facility of its bed hold policy. VI. Staff interviews The business office manager (BOM) was interviewed on 12/9/19 at 12:15 p.m. She said the resident was not issued a bed hold policy when she went to the hospital on [DATE]. She said the facility admission packet contained a copy of the bed hold policy that residents sign as an acknowledgement of receiving the document. She said this resident did not sign the document. She said she was not aware a bed hold policy needed to be provided to a resident when the resident was transferred to the hospital. The NHA was interviewed on 12/10/19 at 8:00 a.m. He said this resident was not issued a bed hold policy when she went to the hospital on [DATE]. He said residents sign a bed hold policy form upon admission to the facility and this resident did not sign the document. He said when a resident was transferred to the hospital, the resident or the resident's representative, were not provided written information regarding the bed hold policy that detailed the duration of the bed-hold in which the resident was permitted to return and resume residency in the facility, nor the reserve bed payment policy in the state plan.

Based on observations, record review and interviews, the facility failed to ensure one (#36) of two residents reviewed out of 33 sample residents received care and treatment in accordance with professional standards of practice. Specifically, the facility failed to accurately and thoroughly complete skin assessments to monitor a bruise to the resident's left forearm. Findings include: I. Facility policies and procedures The Investigating Unexplained Injuries policy, revised (MONTH) 2011, revealed an investigation of all unexplained injuries including bruises, abrasions and injuries of an unknown source would be conducted by the director of nursing (DON) and/or other individuals appointed by the nursing home administrator (NHA), to ensure the safety of the residents has not been jeopardized. Should a resident be observed with unexplained injuries including bruises, abrasions, and injuries of an unknown source, the nurse supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. An injury of an unknown source was defined as an injury that meet both of the following conditions: (1) the source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and (2) the extent of the injury or the location of the injury which was not in an area generally vulnerable to trauma. Documentation should include information of relevant risk factors and conditions that could cause or predispose someone to similar signs and symptoms such as receiving anticoagulants. Any description in the medical record should be objective and sufficiently detailed such as the size and location of a bruise. The nursing staff should discuss the situation with the resident's physician or the medical director to consider whether medical conditions or other risk factors would account for the findings. The resident's physician or the medical director should review and verify conclusions about the possibility of a medical or other similar cause of the findings. II. Resident status Resident #36, age 87, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 10/31/19 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognitive skills for decision making with a brief interview for mental status (BIMS) score of 8 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident did not receive any anticoagulant medications during the assessment period. III. Resident interviews with observations The resident was interviewed on 12/4/19 at 11:34 a.m. The resident had a reddish purple bruise on her left forearm measuring approximately two inches in circumference. The resident said she did not know how this occurred. She said the bruise had been on her forearm for a few weeks. She said the staff had not measured the bruise and she did not think it occurred from receiving a routine blood draw. The resident was interviewed on 12/5/19 at 2:02 p.m. She again said she did not know how the reddish purple bruise on her left forearm occurred. She said it had been there for some time and it did not hurt. IV. Record review Physician orders, dated 9/24/19 at 9:54 p.m., revealed to perform weekly skin observations every Sunday and document findings on the skin observation tool form. Physician orders, dated 9/24/19 at 9:54 p.m., revealed to administer [MEDICATION NAME] (anticoagulant) orally each morning for [MEDICAL CONDITION] reinfarction prevention. The care plan for anticoagulant use, revised on 8/16/19, revealed the resident was at risk for bleeding and bruising easily due to the use of anticoagulant medication for the treatment of [REDACTED]. The care plan did not reiterate the necessity of objectively documenting the description and location of a bruise in the resident's medical record. The skin observation tool, dated 11/10/19 at 9:26 a.m., revealed the resident had a bruise to the left forearm. There were no measurements for this bruise. There were no nurse progress notes to correspond with this skin observation. The skin observation tool, dated 11/17/19 at 6:21 a.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 11/24/19 at 6:21 a.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 12/1/19 at 1:47 p.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The skin observation tool, dated 12/8/19 at 8:23 p.m., revealed the resident did not have any skin integrity issues and the resident was at risk for the development of skin integrity issues. The form noted the resident had healing bruises to the back of her left hand. There were no nurse progress notes to correspond with this skin observation. V. Staff interviews The DON was interviewed on 12/10/19 at 9:27 a.m. She reviewed the skin assessment tool forms. She agreed the skin assessment tool dated 11/10/19 revealed a bruise to the resident's left forearm. She agreed the skin assessment did not contain any measurements or description of the bruise. She said there were no further assessments or investigations related to this bruise. The DON reviewed the weekly skin assessments dated 11/17, 11/24, 12/1 and 12/8/19. She said the bruise to the resident's left forearm was not mentioned on any of the assessments and it should have been documented on each assessment. The DON said a risk management assessment should have been completed in the facility's computerized documentation system, point click care (PCC), for this bruise. She said there was no assessment for this bruise in PCC. The DON said when a bruise was first observed, she or the unit manager should be notified immediately. She said staff would talk with the resident to see what might have caused the bruise. She said a progress note would be made of the conversation and any determination on how the bruise occurred. She said she was unable to find any progress notes regarding a conversation with the resident or a determination of the cause of this bruise. She said nursing staff should follow facility policies and procedures. Licensed practical nurse (LPN) #1 was interviewed on 12/10/19 at 10:26 a.m. He said if he observed a bruise on a resident, he would complete the risk management assessment in PCC. He said the completed assessment could then be reviewed by the nursing staff. He said the DON, unit manager, resident's physician and the resident's responsible party would be notified of the observation. Registered nurse (RN) #2 was interviewed on 12/10/19 at 10:55 a.m. He said when a bruise was first observed, a risk management assessment would be completed in PCC. He said a nurse progress note might also be incorporated in PCC regarding the observation. He said the resident's physician and their representative would be notified of the observation. He said the assessment would be discussed in the next morning meeting. He said all current risk management assessments were discussed in the Thursday morning meetings.

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 resulting in significant/severe weight loss and the facility failed to recognize, evaluate, and address the needs of every resident already experiencing impaired nutrition for one (#63) of two residents reviewed for nutritional status out of 33 sample residents. Specifically, the facility failed to ensure Resident #63 received adequate nutrition resulting in significant/severe weight loss of 9% in one month and 13% in six months. The facility failed to obtain weekly weights for two consecutive weeks as ordered by the physician. The facility failed to assess, evaluate, and document on the resident after Resident #63 experienced significant/severe weight loss. The facility failed to document the resident's physician was notified of the weight loss. The facility failed to assess the adequacy of nutritional interventions resulting in continued weight loss down to 115 pounds resulting in 9.8% weight loss in one month and 13% weight loss in six months. Findings include: I. Facility policy and procedure The Weight Assessment and Intervention policy revised (MONTH) 2008, provided by the director of nurses (DON) on 12/9/19 at 2:15 p.m. revealed, in part, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents . The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month- 5% weight loss is significant; greater than 5% is severe; b) 3 months- 7.5% weight loss is significant; greater than 7.5% is severe; c) 6 months- 10% weight loss is significant; greater than 10% is severe. II. Resident #63 status Resident #63, age 94, was admitted on [DATE] with readmission on 11/5/19. According to the (MONTH) 2019 computerized physician orders (CPO), [DIAGNOSES REDACTED]. The 10/28/19 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. The 11/18/19 MDS assessment revealed a BIMS score was not conducted. The resident was marked as supervised performance for eating with setup help only. III. Observations Resident #63 was feeding herself in the main dining room on 12/4/19 at 12:47 p.m. She was eating half of a peanut butter and jelly sandwich. She had a container of nutritional supplement, a glass of water and a cup of coffee with her meal. Resident #63 was observed on 12/5/19 at 8:30 a.m. in the main dining room. She was able to feed herself. She received toast with butter and poached eggs. She ate approximately 75% of one of the poached eggs and she was feeding herself half of the toast. She also received a cup of coffee, a glass of water, a glass of juice and some orange slices. Resident #63 was observed again on 12/9/19 at 12:52 p.m. in the main dining room. She received a large scoop of mashed potatoes with gravy, chocolate cake, a glass of water and a cup of coffee. She was feeding herself the mashed potatoes. The resident was observed again in the main dining room on 12/10/19 at 8:24 a.m. She received a cup of coffee, orange slices, toast with butter and poached eggs. She appeared weak and had difficulty getting the jelly package open. IV. Record review The care plan, revised 11/25/19, revealed, .is at nutritional risk related to significant weight loss, [MEDICAL CONDITION], GERD, history of refusing meals . benefits from encouragement to come to breakfast, but staff does respect her right to refuse . providing active protein in the afternoon and Juven 2x (times) a day for skin integrity. Interventions included: Notify family and physician of any significant weight changes .snacks between meals as desired and weigh per facility protocol. Review of the most recent RD assessment, completed by the RD on 4/28/18, revealed Regular diet . house supplement once daily . weight: 134 pounds with a body mass index (BMI) of 21.7. Ideal body weight: 130 pounds . weights have fluctuated between 126 and 142 since admitting . estimated needs: 1525-1830 calories; 61 grams protein. There were no recent RD assessments in the resident's chart regarding the resident's readmission to the facility or the resident's significant weight loss. Review of the weights and vitals summary revealed the following: 6/3/19: weight of 132.8 pounds 3/4/19: weight of 122 pounds 11/7/19: weight of 129.8 pounds (after readmission 11/5/19) 11/11/19: weight of 127.6 pounds 11/18/19: Missing weight 11/25/10: Missing weight 12/1/19: weight of 118 pounds (9% weight loss x 1 month and 11% weight loss x 6 months) 12/9/19: weight of 115 pounds (9.8% weight loss x 1 month and 13% weight loss x 6 months) Review of the most recent dietary profile assessment, completed by the certified dietary manager (CDM) on 11/7/19, revealed the resident was on a regular texture diet; power cookie and house supplement. -There were no orders for the power cookie and the house supplement was discontinued on 11/5/19. Review of the (MONTH) 2019 treatment administration record (TAR) and the weights and vitals summary revealed missing weights for 11/18/19 and 11/25/19. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Review of the progress notes revealed the following: -11/5/19: Resident readmitted to facility . with right lung pneumonia . no [MEDICAL CONDITION] noted. -11/6/19 at 16:55: .contacted by (hospice) and they plan to meet with patient to initiate hospice care on 11/7 at 10am. -11/6/19 at 19:21: resident remained in bed for supper. Remains lethargic. -11/7/19 at 8:40: .hospice eval ordered from the hospital . hospice evaluation today. (Signed by the physician) -11/7/19 at 13:34: .up for meals eating more than 50%. -11/7/19 at 19:55: .drinking fluids well. Appetite poor for supper. -11/8/19 at 12:57: .good appetite and fluid intake. -11/14/19 at 11:50: Nutrition Note: Resident's weight is trending up since last month and previous weight loss . Will continue to encourage adequate oral (po) intake and monitor residents weight. There were no progress notes or assessments from the registered dietitian (RD), the interdisciplinary (IDT), or the physician throughout (MONTH) 2019 related to the resident's weight loss. The progress notes did not have any documentation related to the physician notification of the resident's significant weight loss. Review of the (MONTH) 2019 CPO revealed the following: -11/5/19 with a start date of 11/6/19: protein liquid in the afternoon; -11/5/19: Juven two times a day for skin integrity support; -11/5/19 with a start date of 11/11/19: weigh patient weekly on Monday; -11/25/19: hospice There were no physician orders for snacks or any additional supplementation until this week. House supplement was ordered three times a day on 12/9/19. Review of the nighttime (HS) snacks documentation revealed the resident consumed 25-75%. Meal oral intakes revealed variable intakes. V. Interviews Licensed practical nurse (LPN) #4 was interviewed on 12/5/19 at 10:14 a.m. She acknowledged the resident was receiving liquid protein supplement with 70 calories and 16 grams of protein per 30 milliliters (ml) and Juven ([MEDICATION NAME] and [MEDICATION NAME]) twice a day (BID) with 95 calories per packet. The CDM was interviewed on 12/9/19 at 9:24 a.m. She said the RD was contracted and was only in the facility about 10-12 hours/week. LPN #2 was interviewed on 12/9/19 at 10:35 a.m. She said she would assign the weights first thing in the morning and gave the list to the certified nurse aides (CNAs). She said the CNAs should have obtained the weights by 2:00 p.m. or she would have weighed the residents herself. The CDM was interviewed on 12/9/19 at 12:17 p.m. She said she completed the dietary profile for the residents on admission. She said this form contained the resident's likes and dislikes. She said she would have seen the resident if the resident had a weight loss. She said she kept track of the weight losses. She said she would have looked into the electronic medical record for any weight triggers. She said the RD would have looked at some of the weight triggers. She said they had meetings every Thursday and would place interventions as needed. She said snacks could have been ordered or the snacks would have been available upon request. She said she was not sure if this resident had been discussed at the meeting held the past Thursday with IDT. LPN #3 was interviewed on 12/9/19 at 12:29 p.m. She said if the resident had a weight loss, they would notify the clinical manager. She said either the clinical manager or the RD would ask for a reweigh. She said some of the residents had an order for [REDACTED]. She said oh yeah this resident would have taken a high calorie supplement. She said it depended on if they offered the supplement to her. The resident's family was interviewed on 12/9/19 at 12:45 p.m. She said she was aware of the resident's weight loss. She said there was really no food item the resident disliked. She said it took awhile for the resident to finish breakfast and so she would not be very hungry for lunch. She said this resident would have drank a chocolate high calorie supplement all day long. She said the physician and hospice were aware of her weight loss. The RD was interviewed on 12/9/19 at 1:40 p.m. For residents with weight loss, she said she would have talked to the resident and the nurses to see how the resident was eating. She said she would have charted on the resident. She said she would have evaluated what supplements the resident would have accepted. She said they had IDT meetings weekly, on Thursdays. She said she would have to look up to see if Resident #63 had a weight loss. She said she thought this resident may have been on her previous list or the current list for this week. The unit manager (UM) was interviewed on12/9/19 at 1:44 p.m. She said they obtained weights either weekly or monthly. She said the RD would have assessed whether the resident needed weekly or monthly weights. She said the nurse would have documented any refusals in the progress note section. She said they would have notified the physician for any significant weight losses. She said they would have evaluated reasons for the weight loss and obtained any preferences. She said she would assess Resident #63 this day. She said she would talk to the daughter and the RD to see what changes they needed to make. The DON was interviewed on 12/9/19 at 2:15 p.m. She said they interviewed the daughter and the RD had been contacted. She said this resident was not reviewed this past week because they did not have the meeting. She said the RD was not in the building that Friday.

Based on interview and record review the facility failed to ensure one (#2) out of four residents was free from significant medications errors. Specifically the facility failed to administer an intravenous (IV) medication. The facility failed to administer an IV Medication contributing to a significant electrolyte imbalance in the resident which led to her distress and hospitalization . The findings include: 1. Professional references: According to, [DIAGNOSES REDACTED], Nursing Central Diseases and Disorders, Unbound Medicine, 2016, Symptoms vary greatly from patient to patient but usually do not occur unless the potassium drops below 3 mEq/L. Common symptoms include anorexia, nausea and vomiting, lethargy, muscle weakness, and leg cramps. Assess the patient's level of consciousness and orientation. Hypokalemic patients may be confused; apathetic; anxious; irritable; or, in severe cases, even comatose. 2. Resident Information Resident #2, age 68, admitted on [DATE]. According to the face sheet [DIAGNOSES REDACTED]. According to the 9/13/16 minimum data set (MDS) assessment, she was not assessed for cognition, however her previous comprehensive assessment noted a nine out of 15 on her brief interview for mental status (BIMS) indicating moderate cognitive impairment. Record review revealed there was no documented care plan for refusal of care or resident behaviors. 3. Record Review According to the 6/21/16 facility admission History and Physical dated 6/21/16, signed by the primary physician, the resident was admitted to the facility status [REDACTED]. Prior to admission to the facility, the resident had nausea and vomiting and diarrhea for two weeks. Per the History and Physical, the resident reported to the physician she had been nauseated and unable to take her medications, especially potassium. It was also reported to the physician the resident was frequently not taking her medications due to nausea. The Medication Administration Record [REDACTED]. Her documented reason for refusal was consistently nausea and vomiting. A progress note revealed a note from the director of nursing (DON) dated 7/13/16 which documented, DON spoke with (physician name) regarding continued critically low potassium levels and residents (sic) continued declination to take PO (oral) potassium. MD (physician) ordered diluted IV potassium diluted in 0.45% NS (normal saline) in attempt to increase K+ (potassium) levels . Resident notified of orders for IV K+. Stated that she is pleased and prefers to receive it via IV as it does not cause the nausea that the PO does. A. Record Review of missing doses of Potassium According to the July, August and September MARs, the resident was ordered a Potassium IV on the following as follows: July: 7/13/16, 7/15/16, 7/19/16, 7/20/16, 7/22/16, 7/23/16, 725/16, 7/29/16, and 7/31/16; August: 8/2/16-8/15/16 every other day, 8/16/16, 8/18/16; and September: 9/7/16-10/4/16 every other day (ordered following a 9/7/16 lab noting a critical low potassium level of 2.9) B. The Following doses were not given as ordered: July 7/19/16- The MAR indicated [REDACTED]. There was no indication of physician notification or corresponding orders. 7/22/16- The peripheral IV was noted as occluded and an order was placed for a peripherally inserted central venous catheter (PICC- IV access that can remain in the resident for prolonged therapy). There was no order to hold the medication. 7/29/16- The MAR indicated [REDACTED]. There was no accompanying note in the chart, nor any documentation of physician notification or new orders. 7/31/16- Nursing notes stated the resident refused all meds. There was no indication of physician notification or corresponding orders. August 8/12/16-The MAR indicated [REDACTED]. 8/13/16- The medication was given although not scheduled. The corresponding note, at 8:42 p.m. one day after the medication was to be administered, stated, IV pump was located and IV potassium administering. September 9/7/16- an order was entered for IV potassium every other day. The nursing note indicated the resident had a PICC placed but the PICC had to be adjusted at 10:47 p.m. The results were faxed to the PICC placement group. There was no indication in notes or orders of the physician being notified of the delay of treatment or the missed medication. 9/9/16- The nursing note at 4:13 a.m. indicated the PICC line was in place. A note at 11:42 p.m. documented, IV pump missing snap to keep battery in place. Call to pharmacy placed at 2250 (10:50 p.m.) return back at 2340 (11:40 p.m.) pharmacy will deliver pump for next deliver. The resident was not noted as receiving the medication, nor was there documentation of the physician being notified or orders addressing the missed dose. 9/11/16- The MAR indicated [REDACTED]. A note dated 9/12/16 at 2:18 a.m. revealed, The physician requested that the nursing staff call the physicians (sic) office in the morning regarding this resident not receiving her IV Potassium for the past few days due to not having the correct CAD pump. C. Documented Outcome -On 9/9/16 at 9:29 p.m. after the second missed dose of potassium, the resident was noted as, Emotionally upset r/t (related to) potassium deficiency. -A note dated 9/12/16 at 11:34 p.m., after the third missed dose of potassium, revealed, Called into room for c/o (complaint of) not feeling well. Took blood sugar per pt (patient) request for thinking it was really low blood sugar reading 164. Pt stated that she felt very hot and removed all of her clothing provided a cool wash cloth for comfort and turned on pt fan on. Took pt temp to rule out increased temp read 97.3. Provided ice water and Gatorade. Will continue to monitor. - A noted dated 9/13/16 at 12:50 a.m. documented, Notified by CNA (certified nurse aide) that pt wanted to be sent out to ER (emergency room ) for evaluation for chest tightness and fluttering and if this nurse did not send her out that she would call 911 form cell phone. Took V/S (vital signs) for pt ( .vital signs noted with both blood pressure and pulse elevated 154/86, 110). Tried to reassure and redirect pt but pt continued to demand that she be sent out. Contacted (physician's) office and received verbal order form on call to send pt out. Called (ambulance) and pt was transported to (hospital). Son/emergency contact and let him know that pt was being sent out. - According to labs obtained at the facility on 9/6/15 the resident had a critically low Potassium of 2.9. The resident was noted as not receiving any of the doses prescribed as a result of the critically low potassium, and on admission to the hospital the resident's potassium had continued to drop and was 2.6. - Hospital records dated 9/13/16 documented, She (the resident) reports that she has also missed multiple doses of her intravenous potassium secondary to equipment failure at (the facility) . She states that she is very scared and she thinks that something is seriously wrong with her. She states that she knows that her potassium is very low and feels like she is very weak from all her electrolyte imbalances . The patient will have magnesium, potassium and calcium all replaced this evening. She does have chronic [DIAGNOSES REDACTED] and states she has missed a few days of her intravenous potassium which makes sense as to why per potassium is so low today. 4. Interviews a. Resident #2 The resident was not able to be interviewed as she passed away while in the hospital on [DATE]. b. Nursing Staff Licensed practical nurse (LPN) #1, who frequently cared for resident #2, was interviewed on 11/23/16 at 11:21 a.m. regarding medication errors. She said in the instance of not having a medication or an issue with the medication, she would call the pharmacy, then the doctor and see if she could get an alternative if the medication was not in the emergency kit. She said that she was not IV certified and would have to call another staff member to assist her with IVs when ordered. LPN #2 was interviewed on 11/23/16 at 11:24 a.m. He said he would call the pharmacy and tell the unit manager of any medication as well as document in the resident record. He said if a medication was missing the pharmacy could usually deliver it on the next delivery, or they could use a backup pharmacy. LPN #3 was interviewed on 11/23/16 at 1:05 p.m. He said if a medication was not available he would call the pharmacy, call the doctor, and call the family. He said if he was able to obtain the medication, he would administer it if the physician gave approval and if the medication was not available he would get an order to hold it. He said if that was not possible and the medication was missed he would document it as a med error or discrepancy. c. Director of nursing (DON) and Medical Director (MD) The DON and MD were interviewed on 11/23/16 at 11:49 a.m. The DON said the facility did go over medication errors which were defined as a variance from the resident's order. Both the DON and MD said they were involved in a quality improvement plan regarding pharmacy delivery times. When asked about resident #2 specifically, the DON stated the resident refused her IV and pulled her PICC out. She said that if the pump did not work her expectation would be the staff would find a pump that would work and notify the physician and ask for orders. She added the nurses should document what the physician order [REDACTED]. The MD said he did not remember anything being discussed about the pump in morning meeting or with the IDT (interdisciplinary team) but he did recall discussing the patient's issues with medication. He said the pump should not have been an issue and it should have easily been taken care of. The DON said the resident had low potassium when she was admitted , would not take any oral potassium, and was noncompliant with her diet. She said the resident frequently refused all of her medications. When asked for clarification regarding the indication the resident's nausea being noted as a refusal, the DON said that they offered the resident anti-nausea medication and she refused those as well. The DON said if a medication was missed there should be a medication error report for the missed medication. The DON was asked to provide any medication errors regarding resident #2. The DON and nursing home administrator (NHA) were interviewed on 11/23/16 at 12:48 p.m. The NHA said the nurses would document refusals and calling the physician under assessments (none were found on record review). The DON stated there was education they had done on what to do if a medication error occurred. (The medication error and medication administration policies were requested at that time.) In an exit interview with the DON, NHA, and clinical consultant on 11/23/16 at 2:29 p.m. the DON stated there were no medication variance reports (med error reports) created for resident #2. There was also no education regarding the policy available. They were asked to provide any additional information by the end of the next business day; however, none was submitted. d. Physician The attending physician was interviewed on 11/23/16 at 1:51 p.m. with the DON present. He said that he was not the physician that requested the call back on 9/12/16 as he was off. The nurse practitioner who worked with him at that time was no longer working with him or the facility. He said that he did not remember the follow up as the resident went out that night. He had not reviewed any issues with the IV pump. He did recall the IV issue that the facility called him for an order for [REDACTED].>The physician said he did not recall specifically being notified of the resident refusing her IV, but he was notified of her refusing medications. The physician said when the resident received her IV potassium it was effective in raising her potassium levels, and when not on the IV potassium, her labs would trend down. f. Pharmacy A follow up call with the pharmacy manager on 12/1/16 at approximately 2:00 p.m. revealed the facility had sent an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to ensure three of 36 sample residents (#185, #6, and #3) received the care and services necessary to attain and/or maintain their highest practicable level of well being. Specifically: -The facility failed to assess, monitor, and manage resident #185's initial and ongoing pain, contributing to the resident's unrelieved pain, limited mobility and limited sleep. -The facility failed to appropriately position and re-position resident #6 in the Geri chair as documented in the care plan, and failed to appropriately position resident #3 in his wheelchair. The findings include: I. Pain management A. Facility Expectations A review of the facility policy titled Pain-Clinical Protocol and dated 10/2010 revealed the protocol had four pertinent parts applicable for residents with pain. The four areas included assessment and recognition, cause identification, treatment/management and monitoring. - The assessment section of the protocol identified an assessment performed by the nursing staff using a consistent approach and observation of the resident. - The cause identification section involved the provider ordering appropriate testing. - The monitoring section guided the facility staff to reassess the resident's pain and related consequences at regular intervals. The staff will discuss significant changes of levels of comfort with the attending provider. The section of the facility pain protocol titled pain assessment indicated the following facility expectations: - Conduct a pain assessment as indicated. A pain assessment should consist of whether the pain has improved or worsened the general condition of the resident, verbal and non-verbal signs of pain and evaluation of the effectiveness of pain medications. - Document and report the findings of the pain assessment including the effectiveness of pain medications and non-pharmaceutical interventions. The section of the protocol titled administering pain medications indicated the following expected standard of practice: - The pain management program is based on a facility wide commitment to resident comfort. - Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident. - It is very important to recognize cultural influences on the resident's ability or willingness to verbalize pain. Some cultures value stoicism and a high threshold of pain. B. Resident #185 Resident #185, age 30+, was admitted to the facility from the hospital on [DATE]. The face sheet of the same date documented the primary [DIAGNOSES REDACTED]. The admitting physical and history dated 3/5/14 indicated that prior to admission to the facility, the resident had all 10 toes amputated status [REDACTED]. 1. Resident Status Minimum Data Set (MDS) The admission MDS dated [DATE] documented the resident had no speech or cognitive deficits. The resident had no behaviors and did not reject cares. In section J0200 Pain assessment, the resident reported that he was frequently in pain and had difficulty sleeping as a result of uncontrolled pain. In section J0500, the resident reported to the facility that his pain had limited his ability to perform daily activities of living. The resident reported an 8/10 on a pain scale with 10 indicating the worst pain of his life. Orders: The computerized physician orders dated March 2014 documented the following active medications and orders for the resident, both dated 3/25/14, 21 days after the resident was admitted : -[MEDICATION NAME] 5/325mg (3/25/14) one tablet by mouth every 4 hours as needed for pain give one tablet for pain of 1-5 and give 2 tablets for pain of 6-10. -Nursing staff to perform a pain assessment every shift. The resident had no scheduled pain medication and was required by the facility and the provider to ask for pain medication "as needed." Care plan: The care plan dated 3/13/14 documented the resident was care planned for limited physical mobility and pain. The date the care plans were initiated was 3/4/14. The care plan for pain documented the focus as 'the resident having pain related to bilateral toe amputations.' Some of the interventions documented for the resident included: - Anticipate resident's need for pain relief and respond immediately to any complaint of pain. - Evaluate the effectiveness of pain interventions every shift and as needed. The nursing staff will review for alleviation of symptoms, dosing schedules and resident satisfaction with results. - Notify the physician if interventions are unsuccessful or if current complaint is a significant change from resident's past experience of pain. - The staff will review the impact from pain on the resident's functional ability. - Staff will monitor and document the characteristics of pain every shift and as needed. - The non-pharmacological interventions for pain documented in the resident's care plan included positioning. The area titled review was blank and undocumented by the facility staff. 2. Failure to assess, monitor and manage resident #185's pain as expected per facility protocols. a. Observations and Interviews 5/5/14: On 5/5/14 at approximately 3:30 p.m. the resident was observed at the nursing station. The resident was grimacing and said he was waiting for a nurse to come back so he could get some pain medications. He said he was in pain to both of his feet. He stated that the medication he asked for did not totally relieve his pain. 5/6/14: On 5/6/14 at approximately 10:30 a.m. the resident was observed in bed. The resident stated that since he has started weight bearing on his feet his pain is worse and he has to take a break now and again. On 5/6/14 at approximately 1:30 p.m. the resident was interviewed and revealed he was in pain. He rated his pain at level 8/10 (on a 1 -10 scale with 10 being the worst pain). 5/7/14: On 5/7/14 at approximately 10:30 a.m. the resident was interviewed and stated he was in a lot of pain. He rated the pain at 8/10. On 5/7/14 at approximately 2:30 p.m. the resident was interviewed again. -He said the nurses do not always visualize his feet or assess his pain. Rather, they ask him if he is hurting and give him his medications. -He said the nurses don't always come back and ask him if the medication worked or not. He said he has told them that the pain meds were not helping. He said last week his right foot really started to hurt, explaining he has a tight tendon on the arch of his right foot that is tight all the time now. -He said he was unable to participate in therapy this week because he was hurting 'so bad.' He said at night it is hard because he can't sleep; he has to stay awake to ask for his medications. On 5/7/14 at approximately 3:00 p.m. the resident was observed at the nursing station. He stated that he was in pain and was waiting for a nurse so that he could get some pain medication. b. Record Review (1) A review of the nursing progress notes dated 3/5/14 through 5/5/14 and the Medication Administration Records (MARs) for the months of March 2014, April 2014 and May 2014 was completed. The review of the documents indicated frequent PRN pain medication administration and a lack of assessment and monitoring of the resident's pain, as well as a failure to evaluate whether the PRN pain medication ordered was effective and appropriate. -The resident was medicated with the PRN [MEDICATION NAME], the same dose for varying degrees of pain and regardless of effectiveness from 4/1/14 through 5/6/14, a total of 39 times. On some of the dates, the documentation revealed that the resident was medicated 5 and 6 times with the same medication and no re-assessment for effectiveness or pain relief was performed by the facility. -On 3/5/14 at 3:10 a.m., the resident reported pain at a 10/10. Resident was medicated with [MEDICATION NAME] 2 tablets per provider order. The day shift medicated after the report of 8/10 at 10:32 a.m. -On 3/6/14 at 4:21 a.m. the resident reported pain at a 6/10. Resident was medicated with [MEDICATION NAME] 2 tablets per provider order. -On 3/7/14 at 10:00 p.m. the resident was medicated with [MEDICATION NAME] 3 tablets (provider order for 2) and no pain scale was documented. -On 3/8/14 at 2:25 a.m. the resident reported pain and was medicated with [MEDICATION NAME] 2 tablets. No pain scale was documented. -The resident was medicated daily from 3/8/14 until 3/14/14 with provider ordered medications. However, the facility nursing did not document any pain scales for the resident. The next date a pain scale was documented was on 3/14/14. The documentation indicated the resident reported a pain of 8/10 at 11:10 p.m. -There is no documentation in the medical record for the dates of 3/15/14 through 3/20/14; however, the Medication Administration Record [REDACTED]. There are no records of assessments, monitoring or effectiveness of pain medication for five days in the resident's medical record. -There is no documentation from 3/22/14 through 3/27/14 in the medical record. However, the resident ' s MAR for the above dates indicated that the resident continued to receive pain medication for reported pain to the bilateral feet area. The lack of nursing documentation indicated that the resident ' s verbalization of pain and the administration of pain medication was not assessed or reevaluated for effectiveness. -On 3/30/14 the last documentation for 10 days was made. The resident had a new complaint of spasms bilaterally to the feet. The resident's new complaint was not addressed until the documentation on 4/10/14. -On 4/11/14 the resident reported a pain level of 10/10 to the staff nurse (worst pain ever). -On 5/1/14 the resident reported of bilateral foot pain at a 10/10. The nurse medicated the resident with the same medication and dosage that he had been admitted with two months earlier. -On 5/2/14 the resident again reported pain at a level of 10/10. -On 5/5/14 the resident reported pain at a level of 10/10 and the resident reported to the nurse that he had an increase in pain. An x-ray was ordered. (2) A review of the nursing progress notes from the resident's admission date of [DATE] through 5/5/14 indicated that the facility nursing staff did not contact the resident's provider to convey the quantity, duration of the resident's pain and lack of effectiveness of the ordered pain medication. (3) A review of the provider progress notes related to the resident's care and dated 3/5/14 through 3/25/14 indicated the following: -The resident had three documented provider visits. The dates of the provider visits were 3/5/14, 3/11/14 and 3/25/14. A review of the documentation indicated that the provider did not review pain with the resident. The documentation had no mention of current pain regime, relief or needed changes for managing the resident's pain. (4) A review of the physical therapy notes dated 3/19/14-5/5/14 documented the following: -The resident reported a pain level of 8/10 with intermittent bilateral foot pain on 3/24/14 -On 4/23/13 the restorative nurse #5 documented that the resident continued to utilize a level two restorative program with good results. There was no documentation indicating the resident's pain levels or tolerance with therapies. -On 5/5/14 (first day of survey) the therapy department spoke to the resident about increased bilateral foot pain. The resident stated that there was an increase in pain, specifically in the right foot. The therapy documented the presence of a "small lump with extreme tenderness to palpate." 4. Nursing and Medical Provider Interviews The director of nursing (DON), the staff nurse (#3) and the unit manager (#2) where the resident resided were interviewed on 5/6/14 at approximately 2:15 p.m. The interview revealed the following: -The expectation of the nursing management team was that all residents be assessed when they vocalize or exhibit signs and symptoms of pain. -The assessment would include visualization of the area and documentation of the assessment -The resident's sleeping pattern and activities of daily living would be assessed to see if the resident's pain was interfering with the resident's daily life or sleep routine. -The nurse should always assess residents for effectiveness of any medication but especially as needed pain medication. -If a resident had received 39 doses of as needed pain medication, the nursing staff should have reassessed the pain medication, the dosage, the route and the type of medication. After the pain medication has been assessed for effectiveness, the resident's provider should be notified and made aware of the resident's pain issues. The resident's medical provider was interviewed on 5/8/14 at approximately 2:00 p.m. The interview revealed the physician was not aware the resident had received 39 doses of the same pain medication with little effectiveness in relieving the resident's pain. The provider indicated that the facility had not contacted him in reference to the resident until 5/6/14 when the state survey team came into the building. The night nurse #4 was interviewed on 5/7/14 at10:35 p.m. -Nurse stated that the resident had not slept for the last 4-5 days related to increased bilateral foot pain. -The nurse stated that the resident had been receiving as needed pain medication but it did not seem to help as much as the resident needed as he was not sleeping at night. -The nurse did not think that the day shift had notified the provider about the medication not working. A review of the nursing progress notes indicated that the night nurse had not notified the resident ' s medical provider. Reviewed II. Positioning A. Professional references According to DeLisa's Physical Medicine and Rehabilitation, Principles and Practice, Fifth edition (2010), Chapter 78, Wheelchairs, Sitting and Positioning, in pertinent part: "...seating system should be prescribed and designed specific to the user's medical, functional, and personal preference needs. Medically, a system should address issues of soft-tissue management, comfort, reducing the potential for or accommodating orthopedic deformities, and maintaining vital organ capacity. Functionally, the system should address the movements and supports the user needs to reach or access objects, transfer, get under the tables, and perform activities of daily living ... Soft tissue management is a concern for all people who sit for prolonged periods of time and who have compromised sensation or the inability to perform weight shifts ... The loss of sensation is a key factor because discomfort is the usual trigger for shifting and moving. Because the causes of pressure ulcer vary, the choice of seat cushion will vary based on the client's risk factor and the characteristic of the cushion ... Finding a cushion with good airflow and pressure distribution would be important for an immobile client who perspires heavily or is incontinent." According to Fundamentals of Nursing, 7th edition by Potter and Perry (2009), Chapter 47, Mobility and Immobility, in pertinent part: "The terms body alignment and posture are similar and refer to the positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying. Body alignment means that the individual's center of gravity is stable. Correct body alignment reduces strain on musculoskeletal structures, aides in maintaining adequate muscle tone, promotes comfort, and contributes to balance and conservation of energy ... It is particularly important to assess alignment when sitting if the client has muscle weakness, muscle paralysis, or nerve damage. Clients who have these problems have diminished sensation in the affected area and are unable to perceive pressure or decreased circulation. Proper alignment while sitting reduces the risk of musculoskeletal system damage in such a client." B. Resident failures 1. Resident #6 The [AGE] year old resident #6 was admitted to the facility 6/28/13 with [DIAGNOSES REDACTED]. - Record review The minimum data set (MDS) assessment, quarterly review, dated 3/16/14, revealed the resident had no speech, however was able to understand others. Her cognition was severely impaired for daily decision making. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use and personal hygiene. She had functional limitation in range of motion in bilateral upper and lower extremities. The resident was always incontinent of urine and frequently incontinent of bowel. She was at risk of developing pressure ulcers and the treatment included pressure reducing device for chair, bed and repositioning program. Review of the resident's comprehensive care plan (CP) dated 12/31/13 revealed: "(resident's name) is unable to communicate needs or make self understood related to cognitive deficits r/t MS (related to [MEDICAL CONDITION]). (resident's name) is noncommunicative except to say "yes" to everything and to giggle." The Restorative Nursing CP dated 1/22/14, documented: "(resident's name) demonstrates or has potential for: Limited ROM (range of motion) Decreased functional strength Restorative Programs ON HOLD" . The Positioning CP dated 7/2/13 documented impaired positioning related to weakness, limited mobility, contracture and falls with approaches that included: turn and reposition as needed (PRN), monitor skin integrity, Geri chair, foam wedge for trunk support to the left side and elbow flexion foam positioning device. On 3/19/14 the Quarterly Nursing Assessment documented: "Continues with incontinence and is currently a check and change related to cognition. She has had no falls in the last quarter and continues with total dependence for transfers and ambulation. Is at risk for skin break down related to need for assistance with transfers and repositioning. Also has a contraction (muscle/joint contracture) to left arm and arm remains bent up which can cause skin breakdown to inner arm. No current skin concerns. [MEDICATION NAME] powder (Topical Powder used to treat skin infections caused by yeast. It is an antifungal antibiotic) to left inner arm as needed for moisture. Continues to require full assist with all meals. Is currently on scheduled [MEDICATION NAME] (([MEDICATION NAME]) is a narcotic-like pain reliever used to treat moderate to severe pain) and does state "ouch, yea, no, expletive" when left arm is manipulated. OT (occupational therapy) order written on 3/16/14 related to pain in left arm and positioning." Review of the OT evaluation dated 3/17/14 and progress notes dated 4/29/14 revealed the resident had "Kyphotic posture, head forward, head down", however the treatment plan was towards resident's upper extremities contractures and did not address resident's poor and uncomfortable position and body alignment in her Geri chair. - Observations On 5/6/14 at 9:08 a.m., the resident was observed in her room sitting in a Geri chair, sliding down, with no support for her legs, with head down and chin touching her chest, and left arm "pinned" between her body and the arm rest. On 5/6/14 at 4:40 p.m., the resident was observed in her room in the Geri chair. She was in semi sitting position with her head flexed forward with the chin touching the chest and her trunk rotated to the right. She was not sitting on a pressure reducing cushion or any other skin protection. On 5/6/14 at 5:00 p.m., the resident was observed in the dining room in the above described position with feet down on the floor. On 5/7/14 at 8:00 a.m., the resident was observed in the dining room in the Geri chair, sliding down, with her trunk and head forward flexed. 5/8/14 at 9:00 a.m., the resident was observed in her room in semi sitting/semi reclined position in Geri chair with her head flexed forward, and the lift sling under her body. There was no pressure reducing cushion on the chair. - Interviews On 5/7/14 at 9:45 a.m., the OT #1 stated she was working with the resident on her upper extremities ROM. She added that she will observe the resident for positioning during lunch time. On 5/7/14 at 12:55 p.m., the therapy director (OT) stated the resident should have skin protection for her back and sacrum while in Geri chair, and that he ordered today an " overlay with gel seat" for the resident's Geri chair. On 5/8/14 at 9:02 a.m., the CNA (certified nurse aide) #1 stated the resident spends every morning sitting in her Geri chair for several hours and most of the time goes to bed after lunch around 2 p.m. Occasionally the staff scoots the resident up in her chair when she slides down and repositions her elbows. She added there was no planned every two hour reposition for the resident. 2. Resident #3 According to <http://www.therohogroup.com> "ROHO wheelchair seat cushions provide the pressure relief needed. ROHO's unique design allows the seat cushion to constantly adjust to a client's body movement. The adjustment and conformity of the (inter connected air filled) cells accommodate and meet the one-of-a-kind skin integrity needs for each client throughout the day ... ROHO recommends check the air pressure daily if the cushion is properly inflated." The [AGE] year old resident was admitted to the facility 5/7/1999 and re-admitted [DATE] with [DIAGNOSES REDACTED]. The MDS quarterly assessment dated [DATE], revealed the resident had unclear speech, made self understood and was able to understand others. The brief interview for mental status score was 5/15 indicating severely impaired cognition. The resident required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene, and supervision with eating. He was always incontinent of urine, and at risk of developing pressure ulcer with treatments that included pressure reducing device to chair and bed, and turning/repositioning program. Review of the resident's Care Plan (CP) revealed the potential for pressure ulcer development related to immobility was addressed on 4/10/14. The interventions did not include pressure reducing devices i.e. (in example) wheelchair ROHO cushion or its maintenance. The CP did not include scheduled turning/repositioning program. The CP addressed resident's lower extremities limited ROM however did not include appropriate wheelchair positioning as an intervention. On 4/10/14 the Nursing Summary Note revealed: "Resident is able to eat and drink independently. Resident continues on a check and change (for incontinence) r/t (related to) cognitive deficits. Resident requires x 2 (two persons) assist with hoyer lift for all transfers and x 1-2 assist with all other ADL's (activities of daily living). Resident is able to wheel self around in WC (wheelchair)" . On 1/11/14, the nursing note revealed "Resident is incontinent of both bowel and bladder and is on a check and change r/t (related to) cognitive deficits." On 5/5/14 between 12:00 p.m. and 1:00 p.m. and on 5/6/14 at 8:10 a.m., the resident was observed in the dining room sitting in his wheelchair. On 5/5/14 at 4:25 p.m., the resident's wheelchair was observed in his room. The wheelchair ROHO cushion was deflated, had no air. On 5/6/14 at 3:50 p.m., the deflated ROHO cushion was observed on top of the wheelchair in resident's room. On 5/7/14 at 9:50 a.m., the resident was observed sitting in his wheelchair in the hallway. His bilateral lower extremities were flexed and abducted in bilateral hip joints with bilateral knees flexion which was related to short wheelchair foot rests. His trunk was leaning to the right side. On 7/7/14 at 11:55 a.m., the resident was observed in the dining room, in his wheelchair, sitting in the above described position. On 5/6/14 at 3:40 p.m., the certified nurse aide (CNA) #2 who was responsible for the durable medical equipment (DME) stated he ordered for the facility 16 new wheelchair cushions including bariatric, pressure reducing cushion for resident #3. On 5/6/14 at 4:25 p.m., the therapy director stated the resident's deflated ROHO cushion had a hole, and the resident received new temporary bariatric foam cushion. On 5/7/14 at 10:14 a.m., the therapy director stated the resident will require a new wheelchair to improve his sitting position "from frog like to more appropriate" and a new ROHO cushion.

Based on observation, interviews and record review, the facility failed to ensure one (#33) of 36 sample residents was provided with sufficient fluid intake to maintain proper hydration and health. Specifically: The facility failed to identify and assess the resident's risk for dehydration, develop a care plan to mitigate her dehydration risk, and implement hydration strategies to prevent dehydration. The resident was hospitalized with dehydration, kidney failure, and urinary tract infection on 4/10/14. After the resident's return from the hospital, the facility failed to monitor resident #33's fluid intake after she experienced hospitalization and treatment of [REDACTED].#33's risk for dehydration risk and develop a plan of care and implement strategies to ensure resident #33 was meeting her hydration needs. The findings include: A. Professional Reference "Resident Assessment and Monitoring for Long-Term Care: Essential Tools and Guidelines for Clinicians," Barbara Acello, 2006, pages 191 - 200, provides in pertinent part: -Residents known to be high risk of dehydration should be routinely monitored for fluid balance and care planned to address their risk. Residents "at the greatest risk of dehydration" include those who are female, bedridden, have an acute illness; age 85 or older, taking multiple medications and who have multiple chronic illness. -Signs and symptoms of dehydration include elevated blood urea nitrogen (BUN), dry tongue and mucous membranes, poor skin turgor; weight loss (more than 3 pounds in 7 days), vital sign changes ([MEDICAL CONDITION], increased pulse, elevated temperature) and constipation. B. Resident #33 1. Resident #33, age [AGE] years, was admitted to the facility on [DATE]. She was hospitalized [DATE] and re-admitted to the facility on [DATE]. According to the face sheet, resident #33's [DIAGNOSES REDACTED]. According to the 3/16/14 Minimum Data Set (MDS): -Resident #33 was cognitively intact with a Brief Interview Mental Status score of 14/15. Resident #33 had no [MEDICAL CONDITION], behaviors, rejection of cares, or wandering during the MDS observation period. -Resident #33 required extensive assistance with bed mobility, transfers, locomotion on and off the unit, dressing, toilet use, and personal hygiene. She required limited assistance with eating. -Resident #33's height was documented to be 64 inches and her weight was 179 pounds. She did not have an indwelling Foley catheter. 2. Family Interview On 5/8/14 at 11:55 a.m., a family member of resident #33 approached, requesting an interview. The family member stated s/he was concerned that resident #33 was not getting enough assistance with eating or drinking. -S/he said the resident had been on her way to the hospital for a routine care in April when she was emergently hospitalized for [REDACTED]. The family member expressed concern that resident #33 may have experienced further delay in treatment of [REDACTED].#33 had not been going to the hospital for routine cares. -S/he stated that when s/he observed resident #33 in the emergency room , the resident's mouth was very dry, her face was sunken, and the urine in the catheter was dark orange in color. The family member stated that resident #33 was admitted to the hospital for two to three days to "pump her full of fluids" and to treat a urinary tract infection [MEDICAL CONDITION]. -S/he stated s/he now regularly brings liquid treats, like ice cream, to resident #33 to help ensure she is getting enough fluids. The family member stated resident #33 is very accepting of fluid treats. -S/he stated resident #33 came to the facility for rehabilitation after hip surgery and was now on hospice. 3. Record Review a. Hospital Records Patient Summary: In pertinent part, the 4/12/14 patient summary stated that resident #33 was an in-patient at the hospital from 4/10/14 to 4/12/14. The admitting [DIAGNOSES REDACTED]. Emergency Department Notes: The 4/10/14 emergency department notes stated, in pertinent part: - Resident #33 arrived at 7:50 a.m., and was seen at 8:03 a.m. - The "appearance" portion of the "physical exam" stated "The patient is dehydrated and appears frail and elderly." Her skin turgor was listed as "poor." -Abnormal lab values on 4/10/14 at 8:40 a.m., included BUN of 88; Creatinine of 3.79, and a glomerular filtration rate (GFR) of 12. (The national kidney foundation website shows normal value for the BUN is 7-20; normal creatinine levels are less the 1.2 for women; and a GFR of less than 15 indicates treatment for [REDACTED].) -Emergency department nursing note showed resident #33 had a Foley catheter placed at 8:40 a.m. The urine drained by the catheter was "brown-colored cloudy urine." -The "progress and procedure" stated resident #33 was admitted to the hospital for further evaluation, hydration, IV therapy and stabilization of condition. Hospital History and Physical: -The 4/10/14 "History of Present Illness" section stated in pertinent part, "The patient lives in a rehab facility and as per the (family member), s/he checked on her 2 to 3 days ago and she was looking fairly okay, but when s/he checked on her yesterday, s/he found she was dry, dehydrated and somewhat more confused than usual." -The "Assessment and Plan" section stated in pertinent part, "Acute [MEDICAL CONDITION], most likely this is prerenal secondary to dehydration and also the resident is taking ACE inhibitors." b. Facility Clinical Record On 5/8/14 the clinical record for resident #33 was reviewed. The following was noted: Dehydration Risk Screener: -A dehydration risk tool completed on 2/6/14 showed that resident #33 had dehydration risk score of "4.0" on the facility dehydration risk screener tool. The tool did not include a legend/key that interpreted the score. Resident #33's risk factors included that her skin turgor as three seconds; she required assistance with mobility; had one to two "predisposing factors" such as a history of UTI, infection, or pressure ulcer/wounds; and took one to two medications in the diuretic; [MEDICAL CONDITION]; antidepressant, or sedative-hypnotic classes. -A dehydration risk tool completed on 3/9/14 showed that resident #33 had dehydration risk score of "7.0" on the facility dehydration risk screener tool. The tool did not include a legend/key that interpreted the score. Resident #33's risk factors included that her skin turgor as three seconds; she was bed bound; she required assistance with eating; she was incontinent of urine; had one to two "predisposing factors" such as a history of UTI, infection, or pressure ulcer/wounds; and took one to two medications in the diuretic; [MEDICAL CONDITION]; antidepressant, or sedative-hypnotic classes. -No additional dehydration risk tools were identified in the clinical record, including after resident #33 was re-admitted to the facility on [DATE] after a hospital stay, in part, for dehydration, acute [MEDICAL CONDITION] and UTI. Care Plan: The care plan did not specifically address resident #33's risk for dehydration and did not, in other areas, address approaches to help mitigate resident #33's dehydration risk. Fluid Intake and Output Monitoring The clinical record did not include monitoring of fluid intake or output for March 2014, April 2014, or May 2014. There were no meal intake records in the clinical record. Progress Notes: -A Nurse's Note dated 3/25/14 at 2:19 p.m., stated that resident #33 was on antibiotic therapy for treatment of [REDACTED].#33 was encouraged to increase her fluid intake. -Nurses notes from 4/1/14 through 4/8/14 revealed multiple (14) entries about the absence of gastrointestinal upset, nausea, vomiting or diarrhea. None of the nurse's notes from 4/1/14 to 4/8/14 indicated a decrease or change resident hydration status or resident fluid intake status. None of the notes reflected the resident was being assessed for dehydration. -A nurse's note on 4/8/14 at 10:42 p.m., showed resident #33 experienced one episode of diarrhea. -A nurse's noted dated 4/9/14 at 12:21 p.m., stated that the physician was notified of recent change in status. The note stated that resident #33 was isolated in her room during a recent [MEDICAL CONDITION] outbreak (the exact dates were not recorded) and resident #33 did not seem like herself. A request for labs was made. -A nurse's note dated 4/9/14 at 11:32 p.m., stated that resident #33 tolerated the straight catheter procedure. -A nurse's note dated 4/10/2014 at 9:23 a.m., stated, "Resident went out to (hospital name) this morning, left facility at approx 6:30 am for a cerebrel (sic) angogram (sic). Then at approx. 7:30 am Dr. (primary care) called facility and reported to a staff member that resident needed to go to ER dx (diagnosis) [MEDICAL CONDITION] from labs that were drawn stat. When this nurse was informed of resident needing to go to ER; (nurse) reported resident was already out to (hospital). This nurse got lab results and ... spoke with Dr. (on call) and informed him of situation and he reported he would deal with it. This nurse also called (hospital) and spoke with (hospital registered nurse) at the angogram (sic) center and faxed labs to her and informed her of residents (sic) condition per Dr. (primary care). (Hospital Registered Nurse) reported she would call (health organization) and find out what exactly they wanted for resident. Call placed to (resident family member) informing him of residents labs and possible stay at hospital." Dietary/Nutrition Notes: - On 3/27/14 at 12:10 p.m., the Registered Dietician (RD)'s Nutrition Note stated resident #33 had experienced weight loss, in part, due to decrease in [MEDICAL CONDITION]. The RD stated that resident #33 required 2025 ml to 2430 ml of fluids to meet her hydration needs. - On 4/16/14 at 12:10 p.m., the RD's Nutrition Note stated, in pertinent part, "Re-Admission Assessment: Ht: 64 inches, CBW: 159 pounds. Resident is s/p (post) hospitalization for UTI and [MEDICAL CONDITION] - on antibiotics. (Resident) remains overweight; however, further wt loss was unplanned and is not recommended at this time ... She remains on 120ml Med Pass 2.0 three times daily which she usually accepts 100%. She continues w/ moisture related skin damage to her coccyx per weekly wound observation 4/16/14 which is healing ...She did receive IVF (intravenous fluids) in hospital for hydration. Estimated Nutritional Needs ...1800-2160ml fluids.Medication Administration Record [REDACTED] -The April 2014 MAR indicated [REDACTED]. -The April 2014 MAR indicated [REDACTED]. Resident #33 did not receive the evening dose of supplement from 4/3/14 through 4/9/14. Resident #33 consumed half or 60 ml of the morning dose of supplement from 4/7/14 through 4/9/14. Resident #33 consumed none of the afternoon dose of supplement on 4/7/14 and 4/9/14 and only 60 ml of the afternoon dose on 4/8/14. -The April 2014 MAR indicated [REDACTED]. Resident #33 consumed 100% of the juice. -The May 2014 MAR indicated [REDACTED]. -The May 2014 MAR indicated [REDACTED]. -The nutritional supplements provided 891 ml of fluid, if consumed, each day. Labs: - 2/14/14 General Chemistry revealed the following values: BUN = 11 mg/dl (7-23) Creatinine = 0.7 mg/dl (0.6-1.1) GFR = 79.5 ml/min (greater than 60) Resident #33 had normal kidney function and did not demonstrate laboratory signs of dehydration. -3/2/14 Urinalysis (UA) showed resident #33 had a UTI caused by an [MEDICATION NAME] species bacteria. -3/16/14 General Chemistry revealed the following values: BUN = 16 mg/dl (7-23) Creatinine = 0.6 mg/dl (0.6-1.1) GFR = 94.8 ml/min (greater than 60) Resident #33 had normal kidney function and did not demonstrate laboratory signs of dehydration. -4/9/14 General Chemistry revealed the following values: BUN = 75 mg/dl (7-23) Creatinine = 2.9 mg/dl (0.6-1.1) GFR = 18.6 ml/min (greater than 60) Additional information on the results showed that "values between 15 -29 ml/min indicative of severe [MEDICAL CONDITION]." Handwritten notation on the labs results showed that the resident's physician was aware of the lab results and that the resident was to be sent to the emergency room . -4/10/14 UA showed resident #33 had a UTI caused by Escherichia coli. Weights: -On 4/3/14 resident #33 weighed 168.0 pounds -On 4/5/14 resident #33 weighed 155.4 pounds Vital Signs: A review of the vital sign records for resident #33 revealed the resident did not have her vital signs measured and recorded between 4/4/14 and 4/10/14 when she was admitted to the hospital for dehydration and kidney failure. Computerized physician's orders [REDACTED]. The April 2014 CPO showed an order for [REDACTED]. 4. Staff Interviews On 5/8/14 at 2:52 p.m., an interview with the Licensed Practical Nurse (LPN) #2 revealed LPN #2 stated he regularly worked with resident #33 since she moved to the Castle Peak unit. -LPN #2 reviewed resident #33's clinical record for dehydration risk assessment. LPN #2 was unable to explain the values of "4.0" and "7.0" on the dehydration risk screening tool on 2/6/14 and 3/9/14. -LPN #2 stated he was unable to find a dehydration risk assessment for resident #33 after she was readmitted to the facility from hospitalization for treatment of [REDACTED]. However, LPN #2 indicated he was not concerned about resident #33 becoming dehydrated because her current skin turgor was good and her current urine color was good. -LPN #2 acknowledged that the care plan did not address resident #33's dehydration risk. LPN #2 stated he believed that resident #33 did not need a dehydration risk care plan because she was on hospice. LPN #2 stated the unplanned weight loss care plan indicated resident #33 had decreased oral intake, which to him additionally meant there was no need for a hydration care plan. -LPN #2 stated that resident #33 does receive nutritional supplements which boosted her fluid intake. On 5/8/14 at 3:12 p.m., the dietary manager (DM) and the assistant dietary manager (ADM) were interviewed about hydration for resident #33. The interview revealed: -The DM stated that resident #33 was not on any kind of special hydration program. -The DM stated that the facility used to track fluid intake at meals, but stopped when they transitioned to the electronic medical charting. -The ADM confirmed he was unable to locate any fluid intake charting on the resident. -The DM stated resident #33 does not have any special hydration orders or fluid restrictions on her meal card. On 5/8/14 at 3:36 p.m., the Director of Nursing (DON) was interviewed in the presence of Unit Manager (UM) #1. The interview revealed: -The DON stated that resident #33 had experienced a decrease in fluid and food intake prior to her hospital admission on 4/10/14. The DON stated she believed resident #33 had been part of the [MEDICAL CONDITION] outbreak in the facility, which she stated was sometime in March 2014.The DON was unable to state or evidence documentation of an acute care plan to assist resident #33 to maintain her fluid balance during the bout of [MEDICAL CONDITION]. -The DON stated that staff noticed resident #33 was more lethargic on 4/9/14. The DON was not able to explain why vital signs were not monitored for resident #33 from 4/4/14 through 4/10/14, even though the resident was described as experiencing a decreased intake and an increase in lethargy during that time. -The DON stated that stat (urgent) labs were ordered on [DATE], before resident #33 went out to the hospital for a scheduled cerebral angiogram procedure. The DON stated the lab values revealed the resident was dehydrated, experiencing [MEDICAL CONDITION] and had a UTI. She confirmed resident #33 was diverted to the hospital's emergency department for evaluation and treatment. -The DON stated the facility does not document food or fluid intake for its residents. She did not explain how staff monitored fluid intake versus need. -The DON stated that resident #33 had not been re-assessed for dehydration risk upon return to the facility, although the DON acknowledged resident #33 was at increased risk for dehydration. The DON stated there was not a specific dehydration risk care plan in place for the resident but nurses were asked to encourage resident #33 to consume fluids. The DON stated that since readmission, resident #33 was started on nutritional juice and nutritional supplements to assist with wound healing and unplanned weight loss but that increased fluid intake was also a benefit. -The DON stated it was her expectation the resident #33 be offered a drink when snacks are passed and that resident #33 be offered sufficient fluids at meals. 5. Observations On 5/5/14 the meal service in the assisted dining room was observed from 12:06 p.m., to 1:00 p.m. Resident #33 was noted to have meal assistance from a Certified Nurse Aide (CNA) from the outside hospice agency. The hospice CNA intermittently prompted resident #33 to eat and drink, when the hospice CNA was not visiting with residents, staff and others. On 5/7/14 at 8:14 a.m., resident #33 was observed in the assisted dining room. Resident #33 was seated with two other residents at a dining table. Resident #33 was observed to have one glass (approximately 200 ml) of red (cranberry colored) fluids. No other fluids or empty glasses evidencing consumed fluids were present at resident #33's seat. Other residents in the dining room had two or more containers of fluids. No staff was sitting with resident #33 prompting her to eat or drink. Two CNAs were at another table helping dependent diners. On 5/7/14 at approximately 9:30 p.m., an observation of the Castle Peak living unit was done. The observation lasted for approximately one and half hours. -At approximately 9:35 p.m., the day room was observed to have six residents sitting in wheelchairs and watching television. The day room was a common area for the residents, families and visitors to congregate while socializing. -Resident #33 was observed sitting at a dining room-type table, alone. Resident #33 was awake. The five other residents were observed sitting by the television or in other part of the day room. The staff was observed offering 3/5 of the other residents in the day room a beverage. The staff did not approach sample resident #33 and offer any beverages or snacks. There was a unit snack refrigerator approximately 20 feet from where the resident was seated. On 5/8/14 at 11:55 a.m., resident #33 was observed sitting in the Castle Peak common area with her family member. Resident #33 was eating a cup (approximately 12 ounces) filled with an ice cream treat from a local restaurant.

Based on observations, record review and interviews with residents, staff, and the personal care physician (PCP), the facility failed to provide three (#31, #84, and #140) of 49 sample residents the necessary treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. Specifically: -The facility failed to assess, monitor and address skin concerns for residents #31, #84, and #140. These failures contributed to resident #31 developing multiple areas of skin breakdown that triggered pain, hospitalization , amputation and antibiotic treatment. -The facility failed to implement recommendations from therapy to address resident #84 positioning in his wheelchair. The findings include: 1. Resident #31 Resident #31, an [AGE] year old male, was admitted on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. According to his face sheet, his [DIAGNOSES REDACTED]. According to the resident's admission minimum data set (MDS), dated [DATE], he was unable to complete a brief interview for mental status (BIMS) due to cognitive impairment. He was not coded as at risk for pressure ulcers and had no skin issues. a. Observation Observation of the resident on 5/13/13 at 10:00 a.m., revealed a tall, thin man propelling in the hallways in a wheelchair. When addressed by staff and visitors, he responded appropriately. The resident was wearing rubber garden shoes. b. Record review - Development of multiple skin issues - Gaps in assessments, monitoring, and communication of the resident's issues Record review (see below) revealed that after admission the resident developed wounds on his toes and skin breakdown on his buttocks and groin area. When new skin issues were identified by the nursing staff, assessments, documentation and interventions were not completed appropriately resulting in the resident's skin issues worsening. Specifically, record review revealed: A weekly skin assessment dated [DATE] identified the resident had redness to buttocks. There was no further assessment or treatment regarding the resident's buttocks that day. A daily nurse's note dated 1/12/13 at 4:00 p.m., documented the resident complained of pain to coccyx. No assessment was documented in the note or on skin tracking reports. The next skin assessment (due 1/17/13) was not documented. A nursing note dated 1/17/13 at 1:00 p.m. revealed, however, that the resident was making 'sexual' comments to certified nurse aides (CNAs) , pointing to his penis and stating that it needed talking to. He was noted as starting an antibiotic that day for a urinary tract infection [MEDICAL CONDITION]. (A telephone order written earlier that day at 1:00 p.m. confirmed that he was ordered [MEDICATION NAME] 750 mg oral daily for five days for a UTI.) There was no documentation that the resident's groin area was assessed. The next skin assessment documented on 1/24/13 indicated that the resident's skin was dry, but no other issues were noted. A skin assessment dated [DATE] documented that the resident had scabs on the left second and third toes and scabs on the right shin. The scabs were identified as old; however, the previous skin assessment showed no such issues and review of nursing notes revealed that there was no note written from 1/27/13 to 2/3/13. A skin assessment dated [DATE] stated the resident's skin was noted as intact, and review of the nursing notes for 2/3/13-2/7/13 revealed that no skin issues were documented. Review of the 2/14/13 skin assessment revealed the resident had a calloused right hallux, and lateral side of hallux (inside aspect of big toe and foot). The issues were noted as old. Review of the nursing notes revealed that there was no documentation from 2/7/13 to 2/27/13. A physician's note dated 2/27/13 read, "Nursing staff reports no skin problems." Skin assessments dated 2/22/13 and 2/28/13 indicated the resident had calluses on his right hallux. Review of the nursing notes for the time frame of 2/14/13-3/1/13 revealed that there was no request for a referral or mention of a need for further assessment for the resident's skin. A nursing note dated 3/1/13 read, "Resident found with left toe looking dry and calloused. Doctor called. Medi-septic applied resident denied pain ....New orders for toe care noted." A telephone order written on 3/1/13 revealed that the order included to monitor the toe daily as well as apply Medi-septic daily. A note written by the director of nursing (DON) on 3/5/13 stated that they had met for a care conference that day and that there were no skin concerns. The next nursing note was dated 3/6/13 at 12:00 a.m., and stated, "Right great toe pad has 0.5cm opening approximately 0.5cm deep. Area cleaned, TAO (triple antibiotic ointment) applied with dressing. Will have wound nurse assess." Review of the telephone orders revealed that there was an order for [REDACTED]. The note was signed by a nurse other than the wound care nurse. The next note was dated 3/7/13 at 10:00 a.m. and read, "Spoke with wound care nurse about right great toe. Advised to speak with doctor. Called (physician) again." A hospital note written 3/11/13 stated that a note was made on 3/7/13 that the resident was seen by physician; however, no note of a physician visit was located in the resident's record or produced or available when requested 5/13/13 from 6/4/13. The next note of a physician assessment was documented on 3/15/13, when the resident returned from the hospital (see below). A nursing note dated 3/8/13 noted the right toe 'hole' covered. Later that day it was noted that the resident had a red groin and buttocks with small open areas to buttocks. It was noted that a voice mail message was left for the physician and the nurse implemented a treatment of [REDACTED]. A nursing note dated 3/10/13 at 6:00 a.m., documented red, excoriated skin noted to buttocks and groin area. An order was obtained from the on call physician to give the resident a narcotic pain medication prior to cleaning the groin area due to the resident's level of pain. Later that day, the on call physician called and a new order was noted at 9:15 a.m. for [MEDICATION NAME] (anti-fungal) powder to the groin and buttocks. A nursing note on 3/11/13 at 4:20 a.m., by a licensed practical nurse (LPN) documented the resident had a yeasty type rash/excoriation noted to peri area and buttocks. Several small open [MEDICAL CONDITION] were noted between the buttocks with slough. The right side of the penis was noticeably red; more so than the left side. The left foot was noted to be red and hot to the touch. The left foot had multiple scabbed areas. A dressing to the right toe was intact with drainage; however, the resident was noted as upset due to peri cleaning. The resident was noted as having a temperature of 100.4 degrees. A nursing note on 3/11/13 at 5:20 a.m., documented the on call service was contacted and the service nurse recommended the facility send the resident to the hospital via emergent transport. c. Record Review - Hospital Records Record review (see below) revealed the resident was hosptalized on [DATE] for groin pain and foot wounds. It was discovered at the hospital that the resident had severe infections in his foot and groin along with a stage III ulcer on his coccyx. He subsequently had his left great toe amputated. Specifically, record review revealed: A hospital report dated 3/15/13 stated, "(Resident #31) is a [AGE] year old man known to have multinfarct dementia and intermittent [MEDICAL CONDITION] who was sent from his nursing facility for fever and [MEDICAL CONDITION] of his feet. He was found to have osteo[DIAGNOSES REDACTED] of his right great toe. His initial blood cultures started to grow gram positive cocci and right toe grew strep and staph. Later on the blood culture revealed group A and her (sic) foot grew the same organism in addition [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus Aureus). He was admitted and started on IV (intravenous) [MEDICATION NAME] (an antibiotic). Orthopedics were consulted and right great toe amputation was performed. The patient had severe excoriation of his groin area; a CT pelvis was done with results as above. He was seen by urology who thought that it was due to severe fungal infection and recommended [MEDICATION NAME] powder. On admission the patient was noted to have stage III decubitus ulcer and wound care was consulted. He underwent right great toe amputation on 3/12 by ortho. Wound care discharge instructions: Coccyx unstageable pressure ulcer 5 x 2 x 0.3 slough filled ulcer with surrounding (tissue damage)." The resident was readmitted to the facility on [DATE]. According to a readmission hospital note dated 3/15/13, the resident's [DIAGNOSES REDACTED]. d. Facility Response to Resident's Skin Issues Care plan review on 5/13/13 revealed the following: (1) Non pressure tissue damage care plan initiated 1/4/13 revised 3/16/13, and 5/13/13. It stated that the resident was at risk for non pressure tissue damage r/t (related to) decreased mobility. Left second toe; 3/1/13 right second toe, 3/1/13 left top of foot (resolved 4/29/13), and 3/15/13 Right amputation of great toe, resolved 4/29/13, resident has a history of refusing treatments. -Goal was tissue damage will be minimized with interventions over next 90 days. -Approaches included: assess area routinely for changes, provide treatment as ordered, assess pain related to wound routinely, weekly skin checks, IDT (interdisciplinary team) to review PRN (as needed) for any new skin issues, provide positioning devices PRN, dressing change and treatment, and re-approach as needed. (2) Pressure ulcer care plan initiated 1/4/13 revised 3/16/13, 5/13/13 and 5/22/13 (hand written in was 3/15/13 right heel stage two resolved 4/15/13, and 3/15/13 buttocks III resolved). -Goal was pressure ulcer will show signs of healing in the next 90 days. -Approaches included apply pressure reduction mattress to bed, apply pressure reduction cushion to chair or wheelchair, reposition in chair/wheelchair every two hours and as needed, turn and reposition every two hours and as needed while in bed, measure and stage wound weekly, complete a full body skin check weekly, pressure ulcer treatment as ordered, IDT referral PRN and registered dietician, waffle boots, and re-approach as needed. Record review revealed the facility failed to assess the resident's skin weekly (non-pressure care plan above) or conduct IDT reviews as needed and complete full body skin checks weekly (pressure ulcer care plan above). Observations above revealed the resident was not wearing waffle boots as care planned. e. Resident Interview Interview with the resident on 5/13/13 at 10:15 a.m., revealed that he could recall going to the hospital within the past couple of months. He stated that his circumstances surrounding his transfer to the hospital were very painful. He indicated that the pain that he had in his feet was not as bad as the pain that he experienced in his penis and that he feared he would lose it like he lost his toe (see above hospital report). He stated that he tried to tell the nurses that they needed to deal with the issue of the pain in his penis. f. Staff Interview Interview with the nursing home administrator (NHA) on 5/13/13 at 12:20 p.m., revealed they had a new wound care nurse (WCN) who had started in the position on 4/10/13. Interview with the WCN and the Director of Nurses (DON) on 5/13/13 at 12:26 p.m., revealed the following: -If there was an opening or new open area on a resident, the expectation of the facility was that the WCN would assess the wound. The WCN was in the facility twice weekly, so new wounds would be assessed on the next date the WCN was available. At that time the WCN would notify the doctor if that had not already been done at the time the wound was noticed. The WCN would write a recommendation for treatment and turn it over to the unit nurses for follow up. -Facility protocol was to notify both the family and the physician of new wounds and notify the physician of new wound care orders. The DON said her expectation would be that for every new treatment, there would be a note from the nurse indicating that it had been discussed with the physician. -The DON indicated that the floor nurses knew to notify the physician and the WCN of any new skin issues. A non pressure skin condition sheet was to be initiated for all new skin issues and the WCN would fill them out weekly to document the treatment and progress of the wounds. -The WCN stated that she could not locate any non pressure skin condition reports for resident #31 prior to his return to the facility on [DATE]; however, there should have been documentation on any skin openings. The WCN indicated that she could not address resident #31's wounds prior to 4/10/13, as she was not the WCN at the time. -The DON indicated that she was aware the resident's wound care and documentation was not done properly. She stated that there was still no policy specifically addressing how to deal with new skin issues or how to receive orders for treatments. 2. Resident #84, age 86, re-admitted to the facility on [DATE], according to the facility face sheet. His admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS), dated [DATE], resident #84 had severe memory problems. He was able to make himself understood, and understands others. Resident #84 required extensive assistance of one staff member for bed mobility and dressing. Resident #84 was always incontinent of his bowel and bladder and he required total assistance of one staff member for toileting and personal hygiene. According to resident #84's incontinence care plan, dated 5/30/12, he had functional factors that contributed to his incontinence; the goal was to minimize the risk of complications from episodes of incontinence. The pertinent interventions included to provide perineal care daily and as needed, notify the physician as needed. According to resident #84's care plan, he was at risk for pressure ulcers related to decreased activity and impaired mobility. The pertinent interventions included weekly full body checks, apply pressure reduction mattress to his bed and referrals to the dietician and therapy department. a. Skin Breakdown Observations and Interview: On 5/30/13 at 12:41 p.m., observation of the resident's legs revealed multiple scabbed areas on his bilateral lower legs. The scabs appeared as scratches and the resident acknowledged that he had been scratching his legs. The certified nurse aide (CNA) familiar with the resident's care was interviewed on 5/30/13 at approximately 1:00 p.m. She stated resident #84 has had the scratches on both of his legs for weeks. When asked if the resident had any further skin issues, the CNA stated that the resident had some redness to his buttocks. On 5/30/13 at 1:45 p.m., an observation of the resident's skin was performed with the CNA. The skin observation revealed 3 small open areas on the resident's buttock. The CNA stated that this was how the resident's buttocks had looked yesterday on 5/29/13, and she had reported the resident's skin issues to the nurse on duty 5/29/13. On 5/30/13 at 1:50 p.m., a skin assessment of the resident by the licensed practical nurse (LPN) documented that resident #84 had some open areas noted on his left buttock and a scant amount of clear drainage was noted. The LPN, who conducted the 5/30/13 skin assessment and who was familiar with the resident's care, was interviewed on 5/30/13 at approximately 1:50 p.m. She stated that she was not aware that resident #84 had any open areas on his buttocks. The LPN stated that she was not the nurse who worked 5/29/13, but that she would notify the physician regarding the change. Record Review: According to the treatment administration record (TAR), the resident's skin assessment was completed on 5/29/13. The back of the TAR was blank and had no indication that the resident had any skin issues. According to the bathing records dated 5/1/13 through 5/29/13, there were no skin issues identified by the shower aide. According to the weekly skin integrity review dated 5/29/13, resident #84's skin was intact. No skin issues were identified. The nursing notes dated 5/29/13 failed to indicate that resident #84 had any skin issues noted or reported by the staff. Facility Follow up During Survey: A nursing note dated 5/30/13 at 6:30 p.m., after the LPN skin assessment and interview at 1:50 p.m. (see above) read that resident #84 had three red areas to his buttocks noted 5/30/13. One area to his left buttock was open, draining clear fluid. New orders received from the physician. According to the non-pressure skin condition report dated 5/30/13 resident #84 had an open area that measured 1.5 cm in length x 1 cm in width. The wound was noted as identified on 5/29/13; however, this report was not initiated until the wound nurse came in the facility on 5/30/13 to complete an in house skin audit. According to the non-pressure care plan dated 2/24/13, resident #84 was at risk for non pressure tissue damage. The pertinent approaches included: offer protective clothing as resident allows, assess area routinely for changes in size and progress, provide treatments as ordered, weekly skin checks, interdisciplinary team to review as needed for any or as any new skin issues develop, assess medications that affect wound healing and or exacerbate bruising as needed and provide positioning devices as needed. Interview: The Assistant Director of Nursing (ADON) was interviewed in the presence of the unit manager (UM) on 6/3/13 at 2:10 p.m. -The ADON stated the CNA had reported the skin issue to the nurse on duty. The ADON stated that the nurse working on 5/29/13 forgot about it and did not assess the resident. The ADON provided a copy of an employee education dated 5/31/13, showing the nurse was educated regarding inaccurate weekly skin assessments. -The ADON stated that the wound nurse, who generally had Fridays off, was called into complete an entire house audit of resident skin assessments. -The ADON stated that the facility uses the stop and watch tools to provide communication between the CNAs and nurses. The ADON stated that the stop and watch tool should be utilized and resident concerns documented during care. The nurses should then follow up at that point, and she would have expected the nurse to have notified the physician and obtain treatment orders. The LPN familiar with the residents care, and who was working with resident #84 on 5/29/13, was interviewed on 6/3/13 at 2:44 p.m. She stated she remembered the CNA reporting that resident #84 had redness to his bottom on 5/29/13. The LPN stated that she did not assess the resident's skin when the CNA advised her of the issue because it was very hectic, she was extremely busy, and she forgot about it. The LPN stated that the CNAs are suppose to fill out a stop and watch slip and give it to the nurses so that the nurses do not forget about things like this. The LPN stated that the CNA did not fill out the stop and watch form. b. Positioning Record Review: According to resident #84's fall care plan, dated 5/1/12, he was at risk for falls related to new admission, mental status, recent falls, history of previous falls, ambulatory/ incontinent, change in gait pattern, arthritis, dementia, and continues to self propel self throughout the facility. -The fall care plan indicated that the resident had a fall from his wheelchair (w/c) on 10/10/12, 10/22/12, 12/26/12 and 3/15/13. Resident #84 also had two falls from his bed on 12/28/12 and 2/24/13. Nursing notes revealed that on 3/15/13, resident slipped out of his w/c and was found sitting on the floor in front of his w/c. Nursing notes dated 3/20/13 revealed new orders were received for skilled physical therapy to evaluate resident #84. Therapy records revealed: -A physical therapy (PT) evaluation dated 3/18/13. The clinical impression of the PT evaluation dated 3/18/13, read in pertinent part, that resident #84 had significant confusion/dementia and a history of recurrent falls. The resident presented with a sling back w/c with an even seating plane, no w/c cushion, and of lower height in which he can primarily propel his w/c via his bilateral lower extremities and using his upper extremities to reach forward out of the w/c to grab onto hall railing and other objects. Resident was appropriate for a trial of w/c modifications to address fall prevention and assess for comfort and self-efficacy of w/c mobility with modifications. -According to the PT discharge summary, dated 4/8/13, the discharge recommendations were to use a wedged cushion for pressure relief and facilitate fall prevention; use of w/c adjustment for bucket seat to assist the resident from pulling himself down in the w/c, a sling back chair for falls prevention; use of leg rests and bilateral upper extremity propulsion to facilitate falls prevention and avoid pulling force of heel digging of repeated lower extremities propulsion throughout day that slides resident anterior in his seat, creates significant posterior pelvic tilt and pressure to sacrum and increase fall risk. -According to the therapy progress note dated 5/31/13, upon consultation with the clinical care coordinator (CCC) and recent fall of resident, it was observed that the wedged cushion was not currently in use by the resident. The CCC informed PT of staff decision to forgo the w/c leg rests use at this time. CCC reported that staff would relocate wedge cushion for resident use. PT reported that an evaluation was not warranted at this time until previous recommendations were trailed and monitored. Observations: On 5/28/13 at 4:08 p.m., resident #84 was observed sitting in the dining room for breakfast, he was noted to be slouched and sliding out of his w/c. On 5/29/13 at 4:01 p.m., resident #84 was noted in his w/c in the television lounge area, the resident was slouched in his w/c with his buttocks on the edge of the seat. The resident did not have any foot pedals on the w/c. On 5/30/13 at 11:23 a.m., resident #84 was observed using his feet to propel his w/c down the hallway and into the dining room. The resident slouched in his w/c with his buttocks on the edge of the seat. The resident did not have any foot pedals on the w/c. On 5/30/13 at 12:23 p.m., the resident was observed in the dining room. He was slouched in his w/c with his buttocks on the edge of the seat. The resident did not have any foot pedals on the w/c. On 5/30/13 at 1:05 p.m., the resident was observed sitting in the dining room. He was slouched in his w/c. He did not have any foot pedals on his w/c. On 6/3/13 at 12:55 p.m., resident #84 was observed sitting at the dining room table for lunch. He was slouched in his w/c and his w/c did not have any foot pedals. On 6/3/13 at 2:26 p.m., the resident was observed slouched in his w/c, propelling his w/c in the hallway with his feet. On 6/3/13 at 4:05 p.m., the therapy manager observed the resident sitting in the hallway. The resident was sitting slouched in his w/c. There was no wedge cushion present in the w/c. Interviews: The PT who had evaluated the resident on 3/18/13 was interviewed on 6/4/13 at 9:00 a.m. The therapist stated that he assessed the resident's positioning and resident #84 utilized his feet to propel his w/c. This caused the resident to pull himself down and out of the w/c. Leg rests were provided to the resident to prevent him from pulling himself down or out of the w/c and the resident was assessed and capable of propelling his w/c with his upper arms. The front casters on his w/c were raised and a moderately wedge cushion was placed in his w/c to help with pressure relief. -The therapist stated that the unit manager (UM) contacted him regarding the resident's positioning on 6/3/13, and that he first attempted to re-educate the staff regarding the discharge recommendation. However, because of the continued confusion, a new case was opened. Review of the 6/3/13 evaluation revealed it read, in pertinent part, that the patient was assessed and wedged foam cushion was located by the therapy department. PT provided education on previous discharge recommendations, current initiation of reassessment, procurement of appropriate w/c cushion and plan to the east floor nurse. -The therapist acknowledged that the wedge cushion was not in the resident's w/c on 6/3/13 and that staff was having difficulty finding it. The physical therapist stated the nursing staff had decided not to use the foot rests that were provided to the resident. The PT indicated that he did a re-evaluation and a pummel cushion was initiated and staff education was provided. The therapist stated that the previous interventions were re-implemented and agreed that if staff had been following the original interventions, resident #84's positioning would not still have been an issue. See care plan above; the care plan failed to contain any positioning intervention initiated by the therapy department upon discharge from therapy dated 4/8/13. The UM was interviewed on 6/4/13 at approximately 10:00 a.m. The UM stated the therapist had come to her and advised her that the resident was given a pummel cushion for his positioning. The UM acknowledged that staff was not able to locate the original wedge cushion provided by the therapy department. The UM acknowledged that the resident's w/c did not have foot rests applied and stated that the resident refuse them at times. The UM stated that she would expect the nursing staff to be documenting when the resident refused to allow staff to apply the foot rests to his w/c. The UM was not able to locate any documentation to support the resident's refusals. The UM stated that the staff should be applying the foot rests to the w/c as the resident allows. On 6/4/13, during the survey, the UM provided an updated care plan 6/4/13, that indicated the resident often chooses to refuse foot pedals and that staff should encourage the resident to use the foot pedals for w/c positioning as the resident allows. 3. Resident #140, age 75, was admitted to the facility on [DATE], according to the facility face sheet. His admission [DIAGNOSES REDACTED]. According to the minimum data set (MDS), dated [DATE], resident #140 had some memory problems and he was able to make himself understood, and he was able to understand others. Record Review: According to the computerized physician orders [REDACTED]. Cross-reference F279; record review revealed the resident had several nosebleeds, bloody stool, and blood [MEDICAL CONDITION] in 3/13 and 4/13. Review of resident #140's care plans on 5/30/13 at 10:34 a.m., failed to identify a care plan for [MEDICATION NAME], anticoagulant therapy, or risk for hemorrhage (See F279 for further details). Observations: On 5/30/13 at 11:45 a.m., resident #140 was observed lying in bed; he was noted to have dark purple bruising that covered the entire top of his left and right hand and that went from his left wrist to his elbow. On 6/4/13 at 9:00 a.m., was observed for a second time and showed that resident #140 was lying in bed; he continued to have dark purple bruising noted to the tops of his right and left hand, and along his left arm from his left wrist to his elbow. Record Review: According to the admission evaluation and interim care plan dated 3/8/13, section E, skin conditions, was completed on 3/9/13 and revealed that resident #140 had multiple bruises to bilateral arms that were in various stages of healing, and the resident had a port ([MEDICAL TREATMENT] port) to his left upper forearm. The picture in section E had a circle around each arm and to the base of the right scapula (shoulder blade) indicating bruising that was noted on 3/9/13. According to the skin assessments dated 5/8/13, 5/15/13, and 5/23/13 resident #140 was not noted to have bruising to his left arm and bilateral hands. According to the treatment administration record (TAR), resident #140 had a skin assessment on 5/29/13. Review of the back of the TAR for May 2013 showed that it was blank and did not indicate why the skin assessment was not completed on 5/29/13. See above; the wound nurse was called in to do a skin audit of all residents in the facility on 5/31/13 (during survey). According to the skin assessment dated [DATE], resident #140 was assessed as having bruising noted to top of the left and right forearm. The assessment failed to identify the bruising noted to bilateral hands (see observations above). Review of the nursing notes date 5/3/13 through 5/22/13, failed to identify that resident #140 had any bruising noted to his bilateral hands or left arm. Interviews: On 5/30/13 at 11:45 a.m., resident #140 was interviewed and stated that he was on [MEDICATION NAME], which made him bruise easily. Resident #140 stated that for years, any little bump would cause him to bruise. The registered nurse (RN) who was familiar with resident #140 and who identified herself as the wound nurse, was interviewed on 6/3/13 at 12:00 p.m. The RN's stated that the resident has always had discoloration to his arms. The Assistant Director of nurses (ADON) was interviewed on 6/3/13 at approximately 1:00 p.m., and stated that during an abuse investigation on 3/22/13, she had attempted to examine resident #140's hands. At that time did she did not notice any new bruising or red areas. The ADON stated that the resident refused to allow her to turn on the lights and the resident was moving his hands. As a result, she was unable to state if the resident's bruising was as severe as it was now. The ADON, UM, and Director of Nurses (DON) were interviewed on 6/4/13 and stated that when skin issues are noted, that they should be carried forward on the skin assessments until they are resolved. The ADON, UM, and DON were not aware of resident #140 having any new bruising and that no incident reports had been done to identify the ones currently on the resident. The ADON, UM, and DON stated that none of them saw the resident when he was first admitted and were not able to compare the resident's bruising from the time he was admitted to the facility to 6/4/13. Therefore, they were not able to determine if this was a change in condition for the resident. The ADON stated that the bruising may be due to a multitude of labs that have been done for the resident. The ADON stated that she had a call out to the lab to see if they were able to identify what site the labs were drawn and would provide information when it became available. No information was provided by the ADON as of 6/10/13 (Survey exit 6/4/13). Facility Follow up: On 6/3/13 at 2:10 p.m., the ADON provided an employee education form showing that the nurse was educated in accurate weekly skin assessments. On 6/4/13, the ADON, UM, and DON stated that the resident's physician was out of the country at this time; however, they were going to advise the physician's assistant regarding the resident's current condition so that the resident could be assessed.

Based on record review and interview, the facility failed to ensure one of 49 sample residents (#31), who entered the facility without pressure sores, did not develop pressure sores. And, the facility failed to ensure that once pressure sores were identified, care and services were provided to promote healing and to prevent further skin breakdown. Specifically: Resident #31 entered the facility with intact skin. He developed multiple skin issues after admission, including a stage III pressure sore on his coccyx that was discovered when hosptalized on [DATE]. Cross reference F309; the facility failed to assess, document and address the resident's skin issues. The findings include: Resident #31 was an [AGE] year old male admitted on [DATE], discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. According to his face sheet, his [DIAGNOSES REDACTED]. 1. Skin Status on Admission According to his admission minimum data set (MDS), dated [DATE], the resident was unable to complete a brief interview for mental status (BIMS) due to cognitive impairment. He was not at risk for pressure ulcers and had no skin issues. However, review of the admission assessment, dated 1/3/13, revealed the resident was noted as having excoriation on his buttocks. 2. Skin status after admission - intermittent assessment of buttocks/coccyx after admission - development of open areas A weekly skin assessment, dated 1/10/13, identified the resident had redness to buttocks. However, there was no further assessment or treatment regarding the resident's buttocks that day. A daily nursing note, dated 1/12/13 at 4:00 p.m., documented the resident complained of pain to coccyx. No assessment was documented in the note or on a skin tracking tool for pressure or non-pressure wounds. The next skin assessment (due 1/17/13) was not documented. The next skin assessment documented on 1/24/13 indicated that the resident's skin was dry, but no other issues were noted. A skin assessment, dated 1/31/13, documented that the resident had scabs on the left second and third toes and scabs on the right shin. There was no documentation regarding the resident's buttocks. Review of nursing notes revealed that there was no note written from 1/27/13 to 2/3/13. A skin assessment, dated 2/7/13, stated the resident's skin was noted as intact, and review of the nursing notes for 2/3/13-2/7/13 revealed that no skin issues were noted. Review of the nursing notes revealed that there was no documentation from 2/7/13 to 2/27/13. The 2/14/13 skin assessment revealed the resident had a calloused right hallux, and lateral side of hallux (inside aspect of big toe and foot). The issues were noted as old. There was no documentation regarding the resident's buttocks. A physician's note dated 2/27/13 stated, "Nursing staff reports no skin problems." Skin assessments, dated 2/22/13 and 2/28/13, indicated the resident had no skin issues on his backside or coccyx. Review of the nursing notes 2/14/13-3/1/13 revealed that there was no request for a referral or mention of a need for further assessment for the resident's skin. A note written by the director of nursing (DON) on 3/5/13 stated that they had met for a care conference that day and that there were no skin concerns. A nursing note, dated 3/10/13 at 6:00 a.m., that read excoriated skin was noted to buttocks and groin area. An order was obtained from the on call physician to give the resident a narcotic pain medication to be given prior to cleaning the groin area due to the resident's level of pain. Later that day, the on call physician called and a new order was noted at 9:15 a.m. for [MEDICATION NAME] (antifungal) powder to the groin and buttocks. A nursing note, on 3/11/13 at 4:20 a.m., by a licensed practical nurse (LPN) noted that the resident had a yeasty type rash/excoriation noted to peri area and buttocks. Several small open [MEDICAL CONDITION] were noted between the buttocks with slough. The right side of the penis was noticeably red; more so than the left side. The resident was noted as upset due to peri cleaning. The resident was noted as having a temperature of 100.4 degrees. 3. hospitalization [DATE] A nursing note on 3/11/13 at 5:20 a.m., read the on call service was contacted and the service nurse recommended the facility send the resident to the hospital via emergent transport. A hospital report dated 3/15/13 stated, "(Resident #31) is a [AGE] year old man known to have multiinfarct dementia and intermittent [MEDICAL CONDITION] who was sent from his nursing facility for fever and [MEDICAL CONDITION] of his feet ... The patient had severe excoriation of his groin area ... He was seen by urology who thought that it was due to severe fungal infection and recommended [MEDICATION NAME] powder. On admission the patient was noted to have stage III decubitus." 4. Skin status after readmission - untimely interventions to prevent further skin breakdown According to a readmission hospital note dated 3/15/13, the resident's [DIAGNOSES REDACTED]. Nursing assessment on the resident's readmission to the facility on [DATE], documented the resident as having an open area on his coccyx and redness to his right heel. Review of the resident's pressure ulcer care plan (initiated 1/4/13) revealed it was revised 3/16/13. However, it failed to identify the resident had an actual pressure ulcer and failed to include an intervention to reduce pressure while in his wheelchair, or any intervention to reduce pressure to his heels. Review of pressure related monitoring tool dated 3/18/13 revealed that on 3/18/13, the resident was noted as having a stage II on his right heel measuring 1cm x 1.8cm x 0.1cm. It was noted on the pressure ulcer record that the resident removed his waffle boots. No new preventative measure was noted. A telephone order written the same day ordered waffle boots on bilateral feet as much as possible. (There was no order for waffle boots until 3/18/13). A telephone order written 3/22/13 stated to evaluate for seat cushion related to his coccyx ulcer. On 4/10/13 the next assessment of the resident's heel documented he had a stage I 1cm x 1cm x 1cm. The preventative measure was noted to change in position often. Further review of the resident's pressure ulcer care plan revealed it was revised again on 5/13/13 and 5/22/13. Handwritten in was documentation that the 3/15/13 right heel stage two resolved 4/15/13 and the 3/15/13 buttocks III resolved (no date). -The goal was pressure ulcer will show signs of healing in the next 90 days. -Approaches included apply pressure reduction mattress to bed, apply pressure reduction cushion to chair or wheelchair, reposition in chair/wheelchair every two hours and as needed, turn and reposition every two hours and as needed while in bed, measure and stage wound weekly, complete a full body skin check weekly, pressure ulcer treatment as ordered, IDT referral PRN and registered dietician, waffle boots, and re-approach as needed. 5. Resident Interview The resident was interviewed on 5/13/13 at 10:15 a.m., revealed that he could recall going to the hospital within the past couple of months. He stated that his circumstances surrounding his transfer to the hospital were very painful. 6. Staff Interview The Director of Nurses (DON) and wound care nurse (WCN) were interviewed on 5/13/13 at 12:26 p.m. The WCN could not address specific issues with resident #31, as she had stepped into the position of WCN on 4/10/13. -The WCN said the coccyx and heel pressure ulcers should have been documented when they were first identified with detail regarding size, location and appearance. Interventions should have been implemented for both wounds. She stated that his current interventions for heel pressure were his waffle boots which he often refused to wear. She acknowledged that due to his refusal, the waffle boots were an ineffective intervention; however, there was no alternate intervention in place. -The DON stated that the facility had identified that pressure ulcer prevention, documentation and treatment was not done appropriately and their intervention was to change the staff in the position of WCN. -Both the DON and WCN indicated the expectation of the facility was to document the wound, notify the WCN, physician and family, and immediately implement prevention and treatment orders.

Based on observation, staff interviews, and record review, the facility failed to have detailed written plans and procedures to meet all resident emergencies, including those involving seven of 31 sample residents (#102, #179, #68, #89, #119, #116, and #39). Specifically, the facility failed to have a sufficient plan explaining if and where emergency power could be located in the building and how resident care equipment would be powered in the event of a power outage. The facility's failure to ensure an emergency power source was available to enable the suction device for dependent resident #102 created a situation of immediate jeopardy for serious harm. The findings include: I. IMMEDIATE JEOPARDY Observations and interviews revealed the facility had no emergency power source to enable suction devices in the event of a power outage. The facility had power outages in [DATE] and [DATE] [MEDICATION NAME] over six and two hours respectively. The facility did not develop a plan to address how residents who required suctioning would be treated in the event of a power outage. One resident in the facility required chronic suctioning due to severe dysphagia. On [DATE] at 6:17 p.m., the nursing home administrator (NHA) was notified by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failure to ensure an emergency power source was available to enable the suction device for dependent resident #102 created a situation of immediate jeopardy for serious harm. II. FACILITY PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY On [DATE] at 4:18 p.m., the sixth draft of the facility's plan of correction to remove immediate jeopardy was presented. The plan documented in its entirety: -Resident #102 was identified as currently needing intervention. Resident #102's respiratory care plan was reviewed and updated on [DATE]. -The seven residents who may require suctioning or who are deemed a choking risk could be affected if main power source fails and backup power source is not available. The seven residents identified as a possible choking risk have had their Cardex updated and reviewed on [DATE]. Care plans were also reviewed and updated as needed on [DATE]. In the event of power outage residents who have been identified as possible choking risks will be brought to a common area for increased monitoring. A list of all residents identified as a possible choking risk are on a list in the communication book located at each nurse's station as of [DATE]. During a power outage staff are assigned to complete 15 minute room checks. -Suction machines are located on North (Sunlight) office behind the nurse station, on East (Red Cloud/Castle Peak) in the crash cart room, and on Frontier Therapy Center in the Private Dining Room. Currently there is a suction machine located in Room (number) as well. -On [DATE] at around 10:30 p.m., a generator to serve as an emergency power source was made available in the main courtyard, an extension cord leading into the facility made emergency power readily available in case suction machines are needed during a power outage. Staff were educated on how the emergency generator works and how it would be monitored. The generator is located in courtyard off the North hall. To use the generator, apply the choke, turn unit on, pull cord, then switch unit to "run." Use the orange extension cord to run power into the facility. Nurse staff in the facility were immediately in-serviced, and nurse staff is being educated as they come in for their assigned shift. All nurse staff will be in-serviced no later than [DATE]. -On [DATE] four (4) Battery Packs were purchased to be used as a secondary power source should a power outage occur. At 1:30 p.m. on [DATE], the battery packs were inspected, tested and confirmed to be sufficiently charged to run the suction machines for 5 minutes. A third level of backup power is available by using our existing generator (will hold up to four external extension cords) in order to re-charge battery packs if needed. The four battery packs used as a secondary power source are 1500 VA/ 865 Watt units using five (5) battery back-up with surge protection; automatic voltage regulation (,[DATE]) + 11.5%; frequency range of ,[DATE] Hz plus or minus 1 Hz. Lighted bars will show across the front when the unit is adequately charged. Units are charged by AC plug in, will hold charge for up to 164 minutes run time and have ten outlets a piece. Initial charge is similar to a cell phone and takes approximately 16 hours. -On [DATE] dual power source portable suction machines were ordered and will replace the current suction machines on each nursing unit and in room [ROOM NUMBER] as long as Resident requires. These suction machines will be able to operate from either an AC wall plug-in or integral battery power source. These suction machines are described as model (number and company name), which allows for 1.5 hours of run time on the integral battery and features a "low battery light" indicator. An External power pack is located on front of unit. Units will be delivered and in the facility by [DATE]. -NOC (night) RN will check current battery packs and by [DATE] new suction machines daily to assure that each unit is adequately charged. Checks will be logged. Maintenance will check the units for adequate charge as part of their monthly Preventative Maintenance Program. III. REMOVAL OF IMMEDIATE JEOPARDY On [DATE] at 5:10 p.m., after review of the above Plan of Correction, the facility administration was notified that the facility Plan of Correction had been accepted and the Immediate Jeopardy removed. However, deficient practice remained at an F level (potential for harm that is widespread). IV. FAILURE TO ENSURE EMERGENCY POWER SOURCE A. Facility Policy The facility's electrical outage policy updated on [DATE] documented: "1. Supervisor in building will notify maintenance director. 2. Maintenance director may ask supervisor call (the city). Report problems of if electric company is already aware of the situation, ask the following questions: a. Source of trouble. b. Estimated time of outage. c. What assistance they will render the facility. 3. Supervisor will contact administrator and DON (director of nursing). 4. Supervisor will contact fire department if necessary. 5. Alternate power supply of emergency lighting in hallways will activate 6. Nursing staff will be directed to move patients that have 02 (oxygen) to the portable tanks from the concentrators. 7. There will be flash lights at each nurse's station and one in each administrative office. 8. Supervisor will designate staff members to do 15 minute walking rounds of facility if the power is out for more than 10 minutes. Remember that the fire alarm system is not functional in the event of a power outage. In the event this occurs the Colorado Department of Health is to be notified that our power is out. 9. Maintenance Director or designee is responsible to ensure electrical switches are off before electricity is restored, then will turn on switch. 10. If outage will be above and beyond the alternate power source, back-up generator will be used. 11. In the event that there is a power outage due to a snow storm all resident rooms should be checked to ensure that the room is at a temperature of at least 60 degrees. IF the temperature drops below 60 degrees then residents should be evacuated to any areas in the building that are still maintaining heat. 12. If the entire building drops below 60 degrees then refer to the evacuation plan." The plan did not include where to locate details about residents with special needs or who depend on electrically powered care equipment. The plan also did not detail what was powered by the back-up generator. B. Power Outages On [DATE], at approximately 4:30 p.m., the LPN working on the north unit was asked if she was aware of any power outages in the facility. She said in [DATE], there was a snow storm that caused a power outage to the facility. She said she was working and the power was out for over two hours. On [DATE] at approximately 5:15 p.m., the clinical coordinator (RCD) was asked if there had been power outages in the past year. Two outages were identified, one [MEDICATION NAME] six hours on [DATE] and the second [MEDICATION NAME] two hours on [DATE]. On [DATE] at 4:58 p.m., the staff development coordinator provided an undated e-mail sent to the facility staff by the nursing home administrator (NHA). The e-mail documented in pertinent part: "On [DATE], (the city) received 11.5 inches of snow. At the time there was still foliage on the trees. The combination of the depth of the snow and the foliage caused trees to break and power lines to go down. This damage caused (the facility) to be out of power for 8.5 hours. The back-up generator did come on, but after four hours it became evident that the generator was not heavy enough to keep the facility at a proper temperature . . . The kitchen was in an area that had light from the window until sundown. The gas stove was working so residents were able to have hot meals for both lunch and dinner . . . each staff member was asked to write a small analysis of what they did during the outage, what they felt their job was or should have been, and what they felt we did good, and what we could have done better. The general consensus was that the staff did an excellent job of team work. The maintenance department would like to see a bigger generator, and some felt we should have more defined job duties prior to a disaster or drill. Included employee comments showed concern for residents with special needs and a need for clearly defined roles during an electric outage: "Everyone kicked into high gear when the need was evident . . . Specific tasks would be beneficial." "In the future I feel I need to get a roster with all patients/resident special needs sooner . . . " "Frontline staff needs to be better aware of policy and procedures for electrical outage . . . " "I think to improve the situation we should have set assignments of where to go and have specific jobs, assigning management different groups of people or hallways." C. Residents At Risk 1. Resident #102 According to the face sheet, resident #102 was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The [DATE] annual minimum data set (MDS) showed the resident had a long and short term memory problem. He was totally dependent on staff for assistance with bed mobility, locomotion, dressing, eating, toilet use, and personal hygiene. The resident had a swallowing disorder and experienced coughing or choking during meals or when swallowing medications. The resident's [DATE] care plan showed the resident required crushed medications and pudding-thick liquids related to dysphasia. The resident's advanced directive dated [DATE], should the resident be found with no pulse and is not breathing, CPR (cardiopulmonary resuscitation) should be initiated. The [DATE] computerized physician orders [REDACTED]. [MEDICATION NAME] - one patch externally behind ear and change every 72 hours for increased secretions [MEDICATION NAME] 1% drops (4 drops) sublingual every four hours as needed for increased secretions According to the Speech Therapy evaluation and plan of treatment, dated [DATE]: Impressions: "A clinical bedside swallow eval(uation) was completed on pt. He presents with profound dysphagia characterized by a swallow delay of over one minute with premature anterior and suspected posterior spillage prior to swallow, coughing 100% of trials ...Pt was unable to swallow upon command." Skilled Justifications: "Although PT (patient) has a diet waiver to remain on PO intake, SLP has educated family and discussed with MD in past about Pt's (signs and symptoms) of chronic aspiration. Pt exhibits a decline from previous swallow ability." As of [DATE], the resident was ordered foods with pureed texture and pudding thick fluids and had a waiver to do so. According to the feeding recommendations. "I understand the following dietary recommendations have been suggested for (resident). NPO (nothing by mouth) with alternative feeling. I disagree with the above recommendations and understand the potential medical complications [REDACTED]. I request (diet consistency) puree with pudding thick liquids." The nurses' notes were reviewed back to February 2012 and revealed, in pertinent part: -[DATE]: Increased secretions noted during NOC shift. Frequent cough, non-productive. Suctioned PT x 6 left voicemail with (physician). -[DATE]: Suctioned res x 5 times for 4 hours due to increased secretion approx 150 mL of secretion is on collector. Res tolerated well. -[DATE]: Res continues to receive [MEDICATION NAME] to help with fluid secretions. No c/o pain or discomfort voiced or observed. -[DATE]: (2230) Res heard coughing. Walked in and found wife giving res thin liquids. Explained to wife reason res unable to have thin liquids. Res HOB elevated and suction. [MEDICATION NAME] gtts (drops) given to decrease secretions. Pt appears comfortable. No apparent respiratory distress at this time. -[DATE]: Order received. Patient currently on [MEDICATION NAME] drops for increased secretions. Patient continues to have increased coughing episodes. Order received to restart [MEDICATION NAME] 1.5 mg apply behind ear Q 72 hours. On [DATE] at 11:10 a.m., resident #102 was observed in his room. He was sitting in his wheelchair. The resident was aphasic. A suction device was noted on the resident's bed side table, next to his bed. The device was recently used as there was a large amount of yellow mucous observed in the collection container. The suction device was plugged into a standard wall outlet. On [DATE] at 9:15 a.m., three suction devices were observed near the north, east, and frontier unit dining rooms. These suction devices were powered by electricity and were not battery operated. On [DATE], at approximately 4:00 p.m., an environmental tour of the facility was conducted with the environmental director (ED). -The ED was asked if there was an emergency power system in place in the event of a power outage. The ED stated the exit lights were illuminated as they ran off of batteries. The ED stated residents on oxygen concentrators were moved to portable tanks. -The ED, when asked how other resident care equipment, such as, air mattresses or suction devices were powered in the event of a power outage, said the building had a, "mini generator." When asked what the mini generator powered, the ED stated the generator powered some rooms in the assisted living section of the building and some of the front offices. -The ED was unable to identify what outlets specifically received power from the emergency generator. He said, to his knowledge, none of the electrical outlets in the long term care section received power. On [DATE], at approximately 4:30 p.m., and again at 5:20 p.m., the licensed practical nurse (LPN) working on the north unit was interviewed. -When asked if she was aware of any power outages in the facility, she said in [DATE], there was a snow storm that caused a power outage to the facility. She said she was working and the power was out for over two hours. The LPN said there were no emergency outlets located in the north unit, where resident #102 resided. -When asked what she would do in the event resident #102 or the other residents at risk for choking required suctioning during a power outage, she said she would take the resident across the building to the frontier unit because she was sure there were emergency outlets over there. She said she could have the resident there in a "matter of minutes." When asked if she was sure where the emergency outlets were located, she said no. Observation of the frontier unit on [DATE] at 4:50 p.m., revealed no emergency power outlets were able to be identified by the staff. On [DATE] at approximately 5:15 p.m., the clinical coordinator (RCD) was asked if there had been power outages in the past year. Two outages were identified, one [MEDICATION NAME] six hours on [DATE], and the second [MEDICATION NAME] two hours on [DATE]. She also identified seven residents as being at risk of choking (see below). On [DATE] at 5:25 p.m., the nursing home administrator (NHA) was asked if there was a plan in place for emergency power in the event of a power outage. She said they would go to a store to obtain a generator. When asked if there was a plan to power suction devices in the event of a power outage, the NHA said no. She said after the environmental tour, the environmental director made her aware of lack of emergency power. She said she ordered three battery powered suction devices shortly after speaking with the environmental director. 2. Additional Residents at Risk On [DATE] at approximately 5:15 p.m., the RCD identified seven residents as being at risk for choking. Specifically: a. Resident #179 According to the face sheet, resident #179 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The admission MDS dated [DATE] showed the resident received nutrition via a feeding tube and took in 51% or more of his nutritional intake by this approach. The fluid deficit care plan, dated [DATE], showed the resident required honey thick fluids. There was no evidence a dysphagia care plan was implemented. The resident's speech therapy notes were reviewed and showed he began speech therapy on [DATE] due to oropharyngeal phase dysphagia and late effect of [MEDICAL CONDITION] disease. At the start of therapy, the resident was on a feeding tube and could have nothing by mouth. As of [DATE], the resident tolerated pureed diet textures and honey thick liquids for one meal per day. b. Resident #68 According to the face sheet, resident #68 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to the resident's fluid deficit care plan dated [DATE], the resident had dysphagia and required thickened fluids. A diet waiver, dated [DATE], showed it was required the resident received a mixed texture diet with honey thick fluids. However, the resident disagreed with the recommendations and opted to receive a regular diet. c. Resident #89 According to the face sheet, resident #89 was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's contracture care plan dated [DATE] showed the resident had an actual neck contracture. Approaches included to monitor during meals, if difficulty with PO (by mouth) intake notify speech therapy ([DATE]). d. Resident #119 According to the face sheet, resident #119 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's speech therapy notes were reviewed and showed she began speech therapy on [DATE] due to oropharyngeal phase dysphagia and [MEDICAL CONDITION]. The resident was referred to speech therapy because of concerns with the resident's swallowing abilities. e. Resident #116 According to the face sheet, resident #116 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. According to the resident's care plan dated [DATE], "(Resident's) wife will give him thin liquids at times putting him at risk." Approaches included, "Educate family as needed." f. Resident #39 According to the face sheet, resident #39 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The resident's speech therapy notes were reviewed and showed he began speech therapy on [DATE] due to oropharyngeal phase dysphagia. The resident was referred to therapy because his swallowing abilities had declined and his coughing had increased during meals. The resident was deemed to be at risk for aspiration. D. Staff Interview On [DATE] at 2:49 p.m., a RN on the Frontier unit was asked how she would respond to a power outage. She said she would provide the residents with manual bells to replace their call lights. She said there were flashlights located in a drawer at the nurses' station. The RN said she was not aware there were no emergency power outlets located on the unit she was working. On [DATE] at 3:07 p.m., a certified nurse aide (CNA) working on the Frontier unit stated in the event of a power outage, she would place residents who wore oxygen on portable tanks. She would also complete 15 minute checks. The CNA said she was not aware there were no emergency power outlets located on the unit she was working. On [DATE] at 3:36 p.m., a CNA working on the North unit stated she would place residents who wore oxygen on portable tanks in the event of a power outage. The CNA said she was not aware there were no emergency power outlets located on the unit she was working. The CNA looked at the nurses' station to locate a flashlight and was unable to locate one. On [DATE] at 3:50 p.m., a licensed practical nurse (LPN) working on the North unit said she in the event of a power outage she would place residents who wore oxygen onto portable tanks. She said flashlights were located on the nursing carts. The LPN said she knew there was no emergency power on the North unit but thought there was on the Frontier unit because she was able to make coffee there during a power outage. On [DATE] at 4:00 p.m., the NHA stated the Maintenance Director told her the emergency generator supplied power to the six hot water storage tanks in the facility as well as the hot water to heat the facility ([MEDICATION NAME] heat). The NHA stated she was told the emergency generator did not furnish power to any other items. On [DATE] at 4:58 p.m., the NHA said following the two power outages in October and [DATE], there were not in-services provided to staff specifically addressing power outages. She said a general emergency manual training did take place for staff in [DATE]. The NHA reviewed the electrical outage policy and said, "It could probably be written with more specifics included."

Based on record review and interviews, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for four (#190, #182, #42, #47) of 31 sample residents. Specifically; the facility failed to ensure that a resident's pain was managed and appropriately treated and to ensure residents who vocalized pain received pain medication in a timely manner. The findings include: 1. Resident #190 According to the facility admission record, sample resident #190, a [AGE] year old female was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 6/7/12 at 10:32 a.m., the resident was interviewed. She indicated that she had a lot of pain and she had talked to the nurses and the doctor about it. She stated she thought it was getting better and it was better for a short while. However, this morning she stated she had to ask for pain medication at 5:30 a.m. but did not receive the medication until 7:30 a.m., two hours later. The resident indicated she was getting dressed when the nurse came in to her room. She told the nurse she needed something to eat when she took the pain medication, however, the nurse turned away without saying anything. The resident said she hurried to get dressed and followed the nurse to the dining room (DR). The resident continued that the nurse must have gone the other way, because she sat and waited for about 20 minutes in the dining room before the nurse came with her pain medication. The resident indicated that she had arrived at the facility on Tuesday 6/5/12. The resident indicated that when she was at the hospital, she had gotten pain medication at about 10:30 a.m. that day. She said the hospital staff told her that when she got to the facility, all the medication that she needed would be there. The resident stated that at about 1:00 p.m. or so that same day she started to have pain. The resident said she told the nurse about her pain and asked for pain medication. However, the nurse said, "My medications weren't here and that I would have to wait until they got here to have something for pain. The pharmacy was from out of town so she was not sure how long it would take them to get here." The resident indicated that at about 5:00 p.m. she could not take the pain anymore so she asked for some ice packs. The nurse informed the resident that the pain medication had just arrived, "So she brought me some. She also brought me the ice packs. No one came back in to see if the pain medication had worked, to see how I was feeling or to offer me any other pain medication. When I woke up the next morning, I was in so much pain and my leg was very stiff. I asked the nurse why no one had come and she said that I would have to ask for pain medications if I wanted them. I talked to the doctor about that, which would have been Wednesday morning, and told her that I didn't want to have to ask the nurses for the pain medication because I was afraid that I would be sleeping. Then I would wake up in pain like the night before (and this morning). The doctor agreed that it was not acceptable and that she would make sure that I would get the medication every four hours. I also told her that it upset my stomach and made me nauseated if I took it without food, so she said she would also make sure I got food with the medication. It went good for a little while then I asked for some at 9:00 p.m. because I was still up. The nurse came at 1:30 a.m. with pudding and the pain medication; she was so nice. Then at 5:30 a.m., no one came so I had to asked for the medication, and at 7:30 a.m. the nurse finally came." The resident stated this was the story she started with, the nurse coming in and then leaving and so on. At approximately 11:00 a.m., the director of nursing (DON) was informed of the above resident concerns. At 11:51 a.m., the DON was interviewed. She indicated that she had not yet been over to follow up with the resident regarding the concerns related to her untreated pain. The resident's admission evaluation and interim care plan were reviewed; it revealed that on the day of admission, at 1:15 p.m., the resident was having pain in her left hip and calf at a level seven on the one to ten scale with ten being the worst pain. Review of the skilled daily nurses' note (NN) dated 6/5/12 at 1:15 p.m. (the only entry for that date) revealed, in pertinent part, the resident was admitted to the rehabilitation unit, she was alert and oriented x 3, she received pain medication at 10:10 a.m. prior to discharge from the hospital, and she was able to make her needs known. There was no mention of the resident's pain level or pain medication. Review of the Request for Removal of Scheduled II-V Medications, dated 6/5/12, revealed that a request for Narco 5/325 mg was made to the pharmacy. The time written on the form was 1:30 p.m., the fax stamped time to the pharmacy was 15:11 (3:11 p.m.) and the return time stamp from the pharmacy was 16:45 (4:45 p.m.). At 12:03 p.m. the DON was interviewed. She indicated that she was unsure of the actual acceptable time limit to wait for the pharmacy to approve the use of pain medications from the pharmacy emergency kit (E-kit) or unsure how long it should take for the admission medications to be delivered. She said she would expect the nurse to follow-up with the physician and the pharmacy related to the need for pain medications because the resident was having pain. She indicated that she knew the resident was admitted with a pain level of seven out of ten, and that the nurse did not follow-up with the physician or the pharmacy. The DON said there was a need for counseling for the nurse. She indicated that it was her expectation that the physician and pharmacy be followed up with and that it all be documented in the NN. In addition she said non-pharmacological interventions should always be offered for pain relief and documented, especially if pain medication was unavailable. She indicated that she had placed a call to the pharmacy related to the procedure to get narcotics from the E-kit, although she was not sure what the pharmacy expectations were for the turn around on medication delivery and approval for E-kit use. According to the resident's current medication administration records (MAR) the resident received Narco 5/325 mg at 4:45 p.m. on 6/7/12, more than three hours after it was requested. At the end of the day no additional information regarding the pharmacy was provided. On 6/11/12 at 9:52 a.m., the resident was interviewed. She indicated that on 6/9/12 she had her 5:30 p.m. pain medication dose. She then asked for pain medication at 12:30 a.m. (on 6/10/12) because she was still awake, and her pain was about a six or seven. She was told that her pain medication was out, and when she asked for medication out of the E-kit, the resident was told she could have Tylenol and that was it. She said she accepted the Tylenol because she was having pain at a six or seven and she was afraid that her pain would get worse. She said the Tylenol did not help, and the nurse did not offer her anything else to help, like ice packs or anything. The resident said she had to ask her for the ice packs, and after the nurse brought them, she never came back to check on her until she got her pain medication at 3:00 a.m. At that time she was only able to have one tablet of the [MEDICATION NAME] 5/325 mg instead of the normal two she had been receiving. She said it was because she had taken Tylenol at 12:30 a.m. Her pain at that time was about a seven and she had not had any relief. The resident said she was in pain all day on Sunday (6/10/12). She felt like this was because she went so long without pain medication. She said it was a "rough day" and that she was just starting to feel better this morning (6/11/12). She said that a nurse never came in to ask her if she was having pain, or ask her about her level of pain when they brought her pain medication or when she asked for pain medication. According to the resident's current Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documentation on the MAR indicated [REDACTED]. According to the Narcotic count and sign-out sheet, the resident received one tablet of [MEDICATION NAME] 5/325 mg at 2:45 a.m., the first dose signed out on that card. At 10:12 a.m., a nurse working on the rehab was interviewed. She stated that if a resident was out of a narcotic then the nurse should fax a request to the pharmacy for approval to take the medication out of the E-kit. Then if the nurse had not heard back from the pharmacy in about 30 minutes she called them. After the phone call to the pharmacy the medication approval had always come right over. The nurse said she never had to wait after that and said the requests to the pharmacy were kept in the front of the MARs after they were faxed. However, the request in the front of the resident's MAR indicated [REDACTED]. There was a typed sheet of paper in the front of the MAR indicated [REDACTED]. (See below). According to that typed sheet, the resident had agreed to this schedule for her pain medications. "Please try to adhere to it. - 6:30 - with breakfast -12:30 - with lunch -17:30 (5:30) - with dinner -0030 (12:30) - offer with yogurt -6:30 a.m. with breakfast .....and so on. She does understand you will offer her pain medication at the designated times and then you will have to go to the med cart and get them. During between times if she is having pain she would like to have ice offered to her. Remember to try non-pharmacological approaches." The sheet had a typed signature from the DON, however, there was no date on the sheet. At approximately 10:45 a.m., the DON was informed of the above noted concerns expressed by the resident related to not being able to get pain medication, resulting in her experiencing uncontrolled pain for an extended period of time. At 3:14 p.m., the DON was interviewed. She indicated that she explained to the nurse about the memo she put in the front of the resident's MARs. She indicated that she was in the process of doing a pain in-service for the nurses, although she was unsure if the nurse caring for the resident "today" had been educated yet. The DON said she felt that it was concerning and a delay in treatment, that the resident had run out of pain medication and waited so long. She indicated that she was not sure why the medication had not been available or why the nurse had not requested a dose from the E-kit. She had not spoken to the resident or the nurse regarding the concern. Evidence of the in-service training and any follow-up information related to incident regarding the pain medication was requested. On 6/12/12 at approximately 8:15 a.m., the DON provided information related to the in-service on pain. Policy and Procedures and Additional Records Review of the resident's care plan, dated 6/7/12 revealed the resident liked to have her pain managed throughout the day and night during her stay on the rehab unit, and she would like her pain medication given with food. The approaches included following the agreed upon schedule (as above), and to try non-pharmacological approaches: repositioning, relaxation, ice packs etc. Review of the facility pain policy revealed, in pertinent part; -the physician will order appropriate non-pharmacologic and medication interventions to address the individual's pain. -the staff will reassess the individual's pain and related consequences at regular intervals; at each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Review of the pain medication administration in-service revealed; "When you get report from the discharging hospital ask them to medicate the patient for pain prior to discharge (this will buy you some time). It is expected that when a patient is admitted , during your initial assessment you are to ask them about the pain. If, the patient identifies they do have pain you must implement interventions immediately. Try non-pharmacological approaches (repositioning, interventions immediately. Try non-pharmacological approaches (repositioning, ice-packs, relaxation, etc.) Fax your request upon admission to the pharmacy for E-kit access. Document everything in the chart including the time faxed and any follow up calls you had to make, let (name of staff or) myself know if an excessive amount of time has lapsed before a response. Also be sure to document any non-pharmacological approaches you did for the resident. These approaches also are expected for residents that have been with us and may have run out of their medication or were started on a new pain medication regime. We must make pain management a priority for our residents." Review of the facility E-kit's list of medications revealed the narcotic pain medication, [MEDICATION NAME] 5/325 mg was and had been available in the E-kit. 2. Resident #47 Resident #47, [AGE] years old, was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was also on Hospice. Her Minimum Data Set (MDS) assessment, dated 5/11/12, revealed she could understand and was understood and she had short and long term memory loss. She needed minimal assist for transferring, showering, toileting and dressing. She was frequently incontinent of bladder and continent of bowel. She stated she had pain occasionally and her pain was at a 5 out of 10 in intensity. The resident's Pain Evaluation, dated 5/13/12, noted the pain was described as arthritic pain, there was no location of the pain and the resident's pain was a zero. The worst was zero. It also noted the pain was relieved by medication. The resident was on Tylenol one tablet of 325 mg. She also had an as needed order for Tylenol. Her care plan for pain, dated 2/1/11, noted she had the potential for pain. The goal was satisfaction with pain control. The approaches were: relaxation, positioning, administer [MEDICATION NAME] as ordered notify if interventions are not consistently effective. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The order on the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The resident was interviewed on 6/7/12 at 10:19 a.m. She was asked if she had pain. She stated that she often had pain in her right leg. She stated she had broken her hip and had pain in her leg as a result. She stated sometimes it was difficult to walk, although said once she got going she was okay. The resident said she had a friend that came to visit her regularly. The friend was interviewed via telephone on 6/12/12 at 10:35 a.m. She stated the resident complained of pain and the pain was not always in the same place. The hospice nurse was interviewed on 6/13/12 at approximately 10:45 a.m. She stated she had just come from the resident's room. She stated the resident complained of pain and her medication was changed. She stated the resident's new order was for two 325 mg tablets of Tylenol three times per day. On 6/13/12 at 9:10 a.m., a certified nurses aide (CNA) was interviewed. She stated the resident complained of pain; not every day but a few times per week. 3. Resident #42 Resident #42 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her MDS, dated [DATE], revealed she was understood and could understand. She had no memory problems. She needed extensive assist with activities of daily living, She had pain that interfered with her daily activities and her pain was at a 5. Her care plan, dated 9/29/11, showed the resident was at potential risk for pain. The goal was the resident would verbally express increased satisfaction with pain control. The approaches listed included: -exercise program, relaxation and administer [MEDICATION NAME], -monitor resident for signs and symptoms of pain, -notify physician if interventions are not working. The resident stated, on 6/7/12 at 9:51 a.m., that she had pain at about a level 5 on a daily basis. She stated that she had Tylenol 650 mg four times a day. According to the physicians computerized orders for May and June 2012, the resident was to have her pain level checked twice a day by the licensed nurses. Review of the MARS revealed no pain documented for those two months. A frequent visitor of the resident was interviewed on 6/13/12 at approximately 11:00 a.m. The resident was also interviewed at that time about her pain. She stated that she had pain on a daily basis and stated that was to be expected at [AGE] years old. The visitor stated he felt the resident's pain had increased and the resident agreed. She further stated she thought it might be a good idea for something stronger than Tylenol. The nurse practitioner (NP) was in the facility at the same time and was informed of the findings. The NP stated she planned to increase the resident's pain medication. A CNA was asked about this resident's pain. She stated she did have pain and complained frequently. 4. Resident #182 According to the face sheet, the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], showed the resident was cognitively impaired. The resident was not on a scheduled pain management regimen but had received PRN (as needed) pain medication. The resident pain interview showed the resident experienced pain but on a rare basis. The resident's pain care plan dated 5/16/12 showed the resident had a potential for pain related to a chronic disease process. Approaches included: -Positioning/support -Exercise program, stretching exercises -Relaxation -Counseling/support via psychology PRN -Administer [MEDICATION NAME] as ordered -Monitor resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions routinely -Notify physician if interventions are not consistently effective According to the admission evaluation, dated 5/9/12, the resident reported pain in her left leg which she described as "achy" and she experienced the pain daily. The pain evaluation, which was undated, showed the resident had pain or hurting. She rated the pain as being a four on a zero (no pain) to ten (worst possible pain) scale. The June 2012 computerized physician orders [REDACTED]. -[MEDICATION NAME] 650 milligrams (mg) suppository, one suppository rectally every four hours as needed for pain. -[MEDICATION NAME] 325 mg, two tabs orally every four hours as needed for pain. A nurse's note dated 6/10/12 documented a blister on the resident's heel: "Upon apply moisturizer (to) BLE (bilateral lower extremity) R(ight) heel blister pink base, dry skin fell off. Resident states area tender, off loading with pillows, 'gets uncomfortable'. Heel protectors provided." On 6/12/12 at 9:20 a.m., the resident was observed in her room. She was sitting in her wheelchair and watching television. The resident was wearing blue, hard bottomed shoes and her feet were planted on the wheelchair footrests. The resident was asked if she was experiencing pain. She said, "The blister hurts me terrible." On 6/12/12 at 9:42 a.m., the resident's right heel was evaluated by the wound care nurse. The resident said she was having, "a lot of pain in both heels." The resident's shoes and socks were removed. A light purple blister measuring approximately one inch in circumference was noted to the resident's bottom right heel. The resident voiced pain again and said, "That one hurts." The wound nurse pushed on the resident's heel with her gloved hand. The resident said, "Don't push it, it hurts!" The wound nurse did not respond to the resident's complaints of pain or offer her pain relief. On 6/12/12 at 10:32 a.m., the wound care nurse was interviewed. She said she had not informed the floor nurse of the resident's complaints of heel pain, and stated, "I will let her know. She was on break." On 6/12/12 at 10:52 a.m., the licensed practical nurse (LPN) working on the resident's unit was asked about the resident's pain. She said, "I did give her Tylenol because she told me she was in horrible pain." The June 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 6/12/12 at 3:40 p.m., the director of nursing (DON) stated the resident should be offered pain relief if she voiced pain adding, "She should be medicated if she has the order for it."

Based on observation, record review and interviews, the facility failed to ensure one of 38 sample residents (#72) and three supplemental sample residents (#2, #3, #4), received services for prevention and monitoring of skin issues. Specifically, the facility: -Failed to ensure appropriate treatment and services were provided to prevent the development of a stage IV pressure ulcer, and further skin breakdown for resident #72. -Failed to ensure resident #2 received the necessary services for positioning and treatments. -Failed to complete weekly skin assessments for residents #3 and #4, after they were identified at risk for skin breakdown. The findings include: I. Failure to Prevent Pressure Ulcers Facility Policies/Procedures a. Skin/Wound management The facility policy and procedure manual for long-term care, skin and wound management, was reviewed in pertinent part, "Assessment and Recognition - 1. The nurse staff and attending physician will assess and document an individual's significant risk factors for developing pressures sores... 3. The physician and staff will examine the skin of a new admission for ulcerations or indications of a stage 1 pressure area that has not yet ulcerated at the surface...Cause Identification 1. The physician will help identify factors contributing or predisposing residents to skin breakdown...Treatment and Management - 1. The physician will authorize pertinent orders related to wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents...Monitoring - 1. During resident visits, the physician will evaluate and document the progress of wound healing...The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions..." b. Pressure Ulcer Risk Assessment Review of the facility pressure ulcer risk assessment policy (in pertinent part), "1. 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 to that area, which destroys the tissues...4. If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected. 5. Pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. 6. Once a pressure ulcer develops, it can be extremely difficult to heal...9. Pressure ulcers are a serious condition for the resident. 10. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor...Assessment - 2. Skin assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring. a. Staff will maintain a 'skin alert' performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessment at least weekly to identify changes. 4. Because a resident at risk can develop a pressure ulcer within 2-6 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. The admission evaluation helps define those initial care approaches.." c. Pressure Treatment Policy Review of the facility's pressure ulcer treatment policy (in pertinent part); "The purpose of this procedure is to provide the guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Review the resident's care plan to assess for any special needs of the resident..Stage 1 protocol - determine cause of pressure and relieve, redistribute pressure, implement pressure relieving devices, evaluate until redness is no longer persistent, persistent redness is determined only after pressure has been relieved for at least 3/4 of the time it was applied and the redness remains; notify physician, family and appropriate facility personnel, initiate a skin grid and care plan. Incontinence - cleanse with incontinence cleanser, pat dry and evaluate need for protective barrier cream, consider scheduled toileting program, reduce friction or shearing by using transfer techniques and devices as needed..Stage 2, 3 and 4 protocols - protect..." d. Prevention Review of the facility prevention of pressure ulcer policy (in pertinent part), "...The facility should have a system/procedure to assure assessment are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed..." A. Resident #72 Resident #72 developed a stage IV pressure ulcer with osteo[DIAGNOSES REDACTED] three months after admission into the facility. The resident was hospitalized in 3/11 for the wound. Hospice services were initiated and the resident returned to the facility. After her return to the facility in 4/11, further skin breakdown occurred on her spine and heels. Observations revealed staff was not positioning or ensuring offloading devices were effective. More specifically: a. Resident Data Resident #72, [AGE] years old, was admitted to the facility on [DATE]. According to the face sheet, the medical [DIAGNOSES REDACTED]. According to the 1/18/11 Minimum Data Set (MDS - time of admission), the resident required extensive assistance with bed mobility and transfers. The resident was at risk for pressure ulcers and a stage one ulcer was present. The resident was frequently incontinent and ambulated with a walker. Review of the 3/31/11 MDS showed the resident required extensive assistance with bed mobility, occasionally incontinent and had a stage four pressure ulcer. b. Record Review The 1/13/11 admission assessment, the resident scored a 16 on the Braden scale, indicating the resident was at risk for pressure ulcers. Review of the records showed the resident was admitted with compromised skin (four areas of breakdown); treatments were not done and there was a delay in obtaining pressure relieving equipment. Review of the 1/12/11 admission nursing assessment revealed, "coccyx small reddened area. Back mid section reddened skin intact, two bandages covering Left ankle has bandage due to callous... " Review of the 1/12 and 1/13/11 admission skin assessments showed the resident had four areas of compromised skin; spine (two areas), coccyx and heel. The only description noted on this document was "warm, pale and ulcer sore care." -Spine Review of the 1/12/11 admission orders Allevyn every 3 days (last changed 1/12/11)." Review of the January Medication Administration records (MARs) and the Treatment Administration records (TARs) showed the Allevyn treatments were not done according to the physician's orders [REDACTED]. According to the weekly pressure ulcer record, dated 5/20/11, the resident had a stage I ulcer on her upper spine. The monitoring entries included: -5/20/11: reflected the wound bed was red, the surrounding skin color was reddened, the surrounding tissue wound edges were intact, skin prep was applied to area, and hospice was notified on 5/23/11 at 8:45 a.m. -6/15/11: (next entry) reflected the wound bed was pink, the surrounding skin was normal, and the surrounding tissue wound edges were intact. -7/18/11: (next entry) reflected the wound bed was normal, the surrounding skin was normal, and the surrounding tissue wound edges were intact. There were no further monitoring entries. Upon review of the weekly pressure ulcer record, dated 5/20/11 for the upper spine, the designated boxes available to show the family, physician and dietary notification were blank for all entries. According to the nurse's note (NN), dated 5/20/11, no time, the resident had a small open area on her middle back. According to the NN, dated 5/23/11 at 7:45 a.m., a wound assessment was completed by the WCC nurse the resident had a stage I pressure ulcer on her upper spine over a bony provenience that was resurfacing as before. According to the NN, from 5/20/11-7/25/11, there was no further documentation related to the 5/20/11 open area (stage II) on the resident's middle back and the WCC did not address it in her documented wound assessment in the NN, dated 5/23/11 at 7:45 a.m. On 7/27/11 at 12:00 p.m., the director of nursing (DON) was interviewed. She indicated the WCC should have addressed the open area on the resident's middle back in her assessment noted and documented on 5/23/11. If the areas were the same areas then a note should have been provided to explain the documented differences by the nurses. On 7/27/11 at 12:15 p.m., the WCC was interviewed in the presence of the DON. The WCC indicated that when she assessed a wound she recorded it on the weekly pressure ulcer sheets. Left Heel On 1/13/11, staff initiated treatments for the left heel, a stage I pressure ulcer. A dietitian consult was obtained. Multivitamins were ordered and magic cups (dietary supplement) were added to increase the resident's caloric intake. Review of the January 2011 treatment records (TARS) revealed inconsistent treatments to the heel. Out of 59 opportunities, staff treated the heel 36 times. In February, staff treated the heel 29 times out of 46 opportunities. According to the records, the heel pressure ulcer healed on 2/16/11. A 1/19/11 pressure ulcer care plan identified the resident had a stage I ulcer to the left heel, present at the time of admission, related to moisture/incontinence and decreased activity. The approaches included applying pressure reduction mattress to bed, provide incontinence care as needed, complete a full body check weekly, Registered Dietitian consult as needed, pressure ulcer treatments as ordered and wound care nurse to follow the resident. Bilateral Heels On 7/15/11 at 10:00 a.m., the resident's heels were observed, with the floor nurse present. The left heel had a thick dark black scab on it, the surrounding skin was dry and flaky. The floor nurse, with the surveyor present, indicated the scab was approximately 0.4 x 0.3 centimeters in size. The right heel was slightly reddened, the skin was intact. On 7/25/11 at 2:10 p.m., the resident was observed lying in her bed, both heels resting on the bed. On 7/26/11 at 2:15 p.m., the resident was observed lying in her bed, both heels resting on the bed. According to the NN, dated 5/23/11 at 7:45 a.m., a wound assessment was completed by the WCC nurse. The resident had a stage I pressure ulcer on her right heel; it was boggy and mushy. Skin prep was applied and a stage I pressure ulcer on her left heel, was reddened, with no open areas. Skin prep was applied. According to the physician's orders [REDACTED]. -off-load heels while in bed, starting 5/16/11, -apply skin prep to left heel every shift until resolved then as needed, starting 5/16/11. According to the weekly pressure ulcer record, dated 5/16/11 (on-set date), the resident had a stage I on her right heel. The monitoring entries included: -5/16/11: in the section for size in centimeters, depth, exudate, and odor, the wound bed was boggy, surrounding skin reddened, and the surrounding tissue wound edges were intact. Skin prep used for treatment. -5/23/11: (next entry), in the section for size in centimeters, depth, exudate, and odor. The wound bed was boggy, surrounding skin was reddened, and the surrounding tissue wound edges were intact. Skin prep and boots for off loading was used for treatment. The entry reflected the resident did not always wear the boots. -6/8/11: (next entry), the size was N/A, depth, exudate, and odor were blank, the wound bed was boggy, the surrounding skin color was normal and the surrounding tissue wound edges were intact. The treatment was skin prep every day to prevent breakdown. -6/15/11: (next entry), the size was N/A, depth, exudate, and odor were blank, the wound bed was boggy, the surrounding skin color was normal and the surrounding tissue wound edges were intact. The treatment was skin prep to area, improved tissue from last week. Resident refusing heel boots in bed. According to the weekly pressure ulcer record, dated 5/16/11, then crossed out and re-dated 5/23/11, the resident had a stage I on her right heel. The monitoring entries included: -5/16/11: crossed out and re-dated for 5/23/11, the size was red, the depth, exudate and odor were noted as none, the wound bed was boggy, surrounding skin was normal and the surrounding tissue/wound edge was intact. The treatment was skin prep, offloading, heels floated. -5/23/11: crossed out and re-dated as 6/1/11, the size was red, the depth, exudate and odor were noted as none, the wound bed was boggy, surrounding skin was normal and the surrounding tissue/wound edge was intact. The treatment was to continue the same treatment. There was no further documentation related to the right heel ulcer. According to the weekly pressure ulcer record, dated 5/16/11, the resident had a stage I on her left heel. The monitoring entries included: -5/16/11: the size was not measured, the depth, exudate and odor were blank or noted as none, the wound bed was red, the surrounding skin was red and the surrounding tissue/wound edges were peeling skin. The treatment comment area reflects that the area was previously resolved 2/16/11, but pressure reoccurring to area. Skin prep and offloading every shift. Resident had pressure mattress overlay. Hospice informed of skin issue. -5/23/11: the size was not measured, the depth, exudate and odor were blank or noted as none, the wound bed was red, the surrounding skin was red and the surrounding tissue/wound edges were intact. Treatment reflected skin prep and offloading. -6/8/11: the size is N/A, the depth, exudate and odor were blank or noted as none, the wound bed was boggy, the surrounding skin color was discolored and the surrounding tissue/wound edges were intact. The treatment was skin prep, heel protector boots refused by resident, area measured from visible darkened area of heel. -6/15/11: (stage I), the size is measured as 0.7 x 0.5 centimeters, the depth, exudate and odor were blank or noted as none, the wound bed was normal and the surrounding skin color was discolored and the surrounding tissue/wound edges were intact. The treatment was skin prep and float heels as resident continues to refuse boots. -7/6/11: the size was not measured, it was a small red area, the depth, exudate and odor were blank or noted as none, the wound bed was red, the surrounding skin was normal, and the surrounding tissue/wound edges were intact. The treatment was heels floated and skin prep applied. -7/18/11: the size was approximately 0.2 x 0.2 centimeters, the depth, exudate and odor were blank or noted as none, the wound bed was a small dry scab, the surrounding skin was normal, and the surrounding tissue/wound edges were intact. The treatment continued to be skin prep to the heel. -7/25/11: the size was N/A, the depth, exudate and odor were blank or noted as none, the wound bed was boggy, surrounding skin was normal and the surrounding tissue/wound edges were intact. The treatment continued to be skin prep to the heel. There was no further documentation related to the left heel. -Coccyx Although nursing staff noted the coccyx was red at the time of admission, there were no assessments of the resident's skin. The coccyx progressed to a stage four pressure sore within the next few months (see below). Review of the skin care plan showed no care plan revisions that identified the development of the coccyx wound or progression to a stage 4 wound (see time-line below). Three weeks after her admission to the facility, nursing staff discovered a stage II area on the coccyx (information was based on the medical records copied on 5/2/11 - further documentation regarding the resident's skin was submitted after the initial inquiry with conflicting dates-see below): On 2/6/11, the nurse documented, "two blisters noted on left side of coccyx by a Certified Nurse Aide (CNA), reported to wound nurse." Nursing staff applied moisture barrier cream on this day. There were no orders or other interventions at this time. On 2/10/11, the dietitian documented the resident had some recent blisters to buttock. Review of the 2/12/11 nursing monthly summary revealed, "redness on coccyx area, barrier cream applied. Constant 1 staff assist with transfers, incontinent toileting." Review of the medical chart showed no evidence of a bladder evaluation at the time of admission in January or February to assess the resident's toileting needs. On the 2/12/11 monthly sleep summary, "positions self, staff assist at times, usually continent of bowel and bladder. calls for assist to bathroom. occasional episodes of incontinence..skin prep to left heel." Eight days after the coccyx sore progressed into a stage II, on 2/14/11, a dietary consult was requested and a physical therapy evaluation was ordered for a wheelchair cushion assessment. Staff was directed to offload the coccyx every two hours, and apply daily moisture barrier until resolved. Staff inconsistently applied the barrier cream per the physician's orders [REDACTED]. Two days later, an order was written for a pre-[MEDICATION NAME] lab draw (which was within normal range). Per review of the records, an outside therapist saw the resident on 2/13/11 (dates and orders did not coincide) to establish a plan of care and assess for a wheelchair cushion. Ten days later, on 2/23/11, the therapist documented, "discuss concerns with coccyx pressure ulcer. Skilled care facility unable to provide w/c cushion or mattress overlay secondary to (name) of insurance. PT to call insurance provider. The next note, 3/2/11, "..(name of insurance) will not provide any pressure relief systems - mattress overlay on w/c cushion secondary to client resides in skilled care. (Insurance name) feel role of skilled care facility to provide..informed facility to provide (above items)." On 3/3/11, the therapist documented, "..discuss ongoing stage II pressure ulcer on coccyx. (insurance) will not cover any system mattress overlay or w/c cushion." The resident received an offloading cushion for the wheelchair on 3/10/11 (observations below identified staff failed to ensure it was properly inflated for offloading pressure), one month later. A pressure relief mattress was obtained on 3/3/11. B. Inconsistent Completion of Treatment Orders a. Record Review Review of the records showed staff inconsistently completed treatment orders for the coccyx, the sore developed to a stage III ulcer: From 3/1/11 through 3/7/11, staff documented coccyx treatments were completed 3/4- 3/7. There was no indication treatments were performed 3/1/11 through 3/3/11. The area had progressed to a stage III pressure ulcer. Review of the medication records (MARs) revealed the resident was complaining of increase coccyx and back pain beginning on 3/3/11 and Tylenol was administered. On 3/7/11, the order was changed to treat the coccyx, "cover coccyx area with foam dressing after applying Calazyme paste to wound every day until resolved." On 3/7/11, the wound care nurse reassessed the resident's risk factors and interventions, "overall Braden score of 19, incontinent of bowel and bladder, non-compliance, pain and [MEDICAL CONDITION]." On 3/10/11, the resident was seen by the wound care center. On 3/10/11, an antibiotic was ordered for ten days to address a wound infection in the coccyx area. Orders were written to continue wound care treatment and offloading. Review of the March TARs revealed treatments were completed 3/7 through 3/14/11. Four days later, on 3/14/11, the order changed to "[MEDICATION NAME] gel to wound bed every day, cleanse wound first with wound cleanser, skin prep to periwound, cover with [MEDICATION NAME] (an antimicrobial dressing) until resolved." Review of the TARs showed treatments were done 3/14, 3/15 and 3/16. On the TAR, there was handwritten information to nursing staff, "3/16/11 - complete pressure relief to wound area, reposition on sides only. Encourage patient to ambulate ad lib, encourage to get up for meals and set on pressure relief cushion at all times. When in chair have a pillow to her back and encourage sitting up off coccyx." Review of the 3/14/11 resident infection screening document revealed, "pressure ulcer - coccyx wound - developed as primary wound from resident using walker as chair." On 3/16/11, the resident was seen by the wound care center. Review of the 3/22/11 monthly nursing summary, "stage 4 on coccyx, set up help with transfers and continent of urine..see notes under skin tab for ongoing coccyx wound treatment. Offloading as much as possible, meticulous use of waffle cushion. Dakins solution prescribed for wound infection. Weight decrease every week, supplements encouraged, but resident not always compliant with offloading/hydration." On 3/22/11, the Tylenol was changed to a scheduled dose three times a day. Treatments were completed 3/18/11 through 3/29/11. Another hand written entry on the MAR, dated 3/29/11, "offload sacral at all times." On 3/31/11, the resident was directly admitted from the doctor's office to the hospital with a stage IV open wound with osteo[DIAGNOSES REDACTED] (a bone infection). Surgery was recommended to treat the ulcer but comfort measures were discussed. The resident returned to the facility on [DATE] under hospice care. b. Interventions The facility provided documentation labeled, "repositioning" for the months of January through April. On this document, there were daily staff initials. Per the Director of Nursing (DON), this document was signed off by the Certified Nurse Aides (CNAs) indicating the resident had been repositioned during the three shifts. Observations revealed staff did not position the resident and further breakdown occurred after the resident returned to the facility in April. On 7/26/11 at 2:15 p.m., observed the resident in her bed, her wheelchair was next to the bed and the air cushion was flat. c. Skin assessment and monitoring Skin assessment and monitoring of the wounds (from the first review of the medical records conducted on May 2, 2011), the following documents were located in the chart: -A weekly pressure ulcer record, dated 1/13/11, indicated there was a stage one pressure ulcer to the left heel. There was no assessment of the size, depth or exudates. The nurse documented there was no odor; the area was soft/mushy, normal surrounding cover, and pink surrounding tissue. There was no further monitoring of the wound noted on 1/13/11. Although, nursing staff noted the resident's coccyx was red at the time of admission, there was no monitoring or skin assessment until 2/14/11 (upon first review of the record 5/2/11). The onset date was 2/10/11. Review of this weekly pressure ulcer record, started on 2/14/11 (four days after the onset), showed, "stage 2 ulcer, 6 x 3 cm (centimeters), no depth, serous drainage, no odor, no redness, normal skin color and pink surrounding tissue." Per this document, the dietitian and physician were notified. Treatment interventions included turning the resident every two hours, offloading pressure, moisture barrier every shift; a therapy evaluation for a cushion and a dietary consult. The next entry was, dated 2/21/11, with wound measurements. The pre-[MEDICATION NAME] was drawn on 2/24/11. The wound nurse documented, "Ulcer healing as measurement shows 3 areas of opening within this 1 measurement. Calazyme paste effective, frequent reminding of offloading to both resident and family members." Additional record review revealed there were no other measurements found of this wound in the chart. Review of the March weekly pressure ulcer record showed the wound care nurse monitored the wound on 3/14, 3/21 and 3/29/11. On 3/14, the resident's wound progressed to a stage 3. The wound care nurse documented, "MD faxed with concerns of slough flap over wound bed. Appears to need surgical debridement. [MEDICATION NAME] gel applied to wound bed, skin prep to periwound, antimicrobial, [MEDICATION NAME] dressing changes every day, offloading as frequent reminders, cushioned chairs and pressure mattress. Family informed of treatment. turn every two hours, pressure mattress honeycomb cushion for wheelchair." On 3/21/11, the wound progressed to a stage IV. The nurse documented, "Waffle cushion accompanies resident to dining room and all sitting areas. Res. positioned on side in bed. Treatment changed to Dakin's solution/packed sterile tape, antifungal barrier cream, Keflex antibiotic treatment last day today. Family informed. Follow up to be scheduled with MD. Turn every two hours, pressure mattress." On 3/29/11, the nurse documented, "wound odor pervasive, 90% slough in wound bed, MD notified, appt. to be moved up to wound clinic. turn every two hours, waffle cushion when sitting, offloading." Review of the 4/1/11-4/5/11 hospital records showed a [DIAGNOSES REDACTED]. Wound care evaluated the patient and felt that the sacral decubitus ulcer was stage IV (could not see bone, but could palpate via sterile glove). MD visits on 2/9/11 were without mention of skin issues (although two blisters noted on 2/6/11). C. Record Review-Conflicting Documentation Additional chart review on 5/31/11 revealed documents and assessments currently in the medical chart were not previously present during the initial medical record review on 5/2/11. Left Heel - another assessment was now documented on the weekly pressure ulcer record. T here was a 1/13/11 assessment. The next assessment, dated on 2/16/11, showed the area had resolved. Coccyx - The weekly pressure ulcer document showed an onset date of 2/6/11 instead of 2/10/11 (2/10/11 was crossed out and 2/6/11 written without any indication of backdating). The assessments were conducted on 2/14, 2/21; and now, 2/24, 3/3 and 3/7 (not previously in the resident's record). On 3/3/11, the facility documented a pressure overlay mattress was obtained. On 3/7/11, the wound care nurse documented, "offloading as much as possible when resident compliant. Continues to sit on walker when in room, needs reminders for offloading." A new weekly pressure ulcer record, dated 2/6/11, was initiated for the coccyx wound (again not present on the first review of the medical record). The form indicated a stage 2 pressure ulcer was present but not measured. The wound care nurse documented, "Res. noticed in shower to have serous filled blister area on left side of coccyx, area opened shortly after shower. Moisture barrier applied today. Family aware of problem. Res. currently prescribed [MEDICATION NAME] for respiratory issues." There were no preventive measures from this assessment. D. Staff interviews On 5/2/11 at 3:50 p.m., the wound care nurse (WCN) stated she was scheduled to monitor wounds once a week; otherwise she worked the floors as a medication nurse. The WCN stated she tried to measure the wounds once a week but was not always able to see everyone weekly. The WCN continued, stating staff would alert her of any skin problems found during cares or showers. Floor nurses were also to monitor the wounds and perform dressing treatments as ordered by the physician. Floor nurses were responsible for weekly skin assessments. The WCN stated she would communicate with the physician about wounds and would alter treatments if no improvements were noted after a two week period. On 5/2/11 at 2:07 p.m., a hospice care provider stated multiple cushions were tried but often the resident refused. The nurse stated the resident liked the waffle cushion, but "it was not very supportive." On 5/2/11 at 3:24 p.m., the facility was asked to demonstrate how stage IV pressure was unavoidable. The facility response was they would investigate. On 5/31/11 at 11:45 a.m., the DON stated the facility utilized standing policies for pressure and non-pressure treatments. The DON made the following comments, "if a wound was identified, we assess, notify the physician and obtain orders for treatments. The primary nurse was responsible for overall management of wounds and medical records. The WCN conducted rounds a couple times a week and she follows continuity of wound care needs. The WCN also worked the floor. Staff would notify the WCN about skin issues and place on the 24 hour report. This information would be reviewed and orders reviewed to ensure if appropriate treatments, notification completed and working in conjunction with the primary nurse. The WCN also worked the floor and treatments could be done by her if she was the floor nurse. The nurses on the floor could measure but skin nurse could measure as well. The WCN turned in weekly reports with skin measurements on all pressure ulcers. The DON felt the measurements were being done on a weekly basis because she reviewed the reports. The primary nurse on the floor was responsible for completing the weekly skin assessment and staff would document the assessments in the skin book or skin section found in the medical chart. The CNAs would be responsible for repositioning residents and turning. Daily dressings were completed by the primary nurse. Nursing staff could contact the physician if a wound was not doing well. Nursing staff would contact family/responsible party. Equipment needs/recommendations would be given to the DON, who would order the equipment. CNAs had ADL books for resident information and they could refer to the care plans as well. The facility had team lead CNAs and they would update ADL books and pass on information. The facility had consistent staff assignments, shift to shift reports and staff could look at the skin assessments to update families with information." The NHA (also present) stated morning meetings occurred to discuss resident issues as well as hall huddles with floor staff. The DON stated she felt the facility did a lot of interventions for this resident. Staff documented repositioning had been completed. On 5/31/11 at 12:56 p.m., the WCN stated the wound sheets were not in the chart and she had a stack of assessments in her records. On 6/1/11 at 11:45 a.m., the WCN stated she felt the resident was at risk for skin breakdown due to her co-morbidities; falls, [MEDICAL CONDITION], decrease compliance, removing pressure devices, weakness, decrease fluid intake and oral intakes. On 6/1/11 at 1:45 p.m., the DON stated if the resident's insurance would not pay for equipment the facility would provide. The DON felt like they did a lot of work with this resident, and acknowledged maybe the documentation was not always there. The DON stated the administration recognized the issue of skin assessments not being completed and re-inserviced staff. Interventions included therapy referrals, interdisciplinary team discussions, dietary interventions and the resident was non-compliant (unable to show continued non-compliance). The DON acknowledged the resident's care plan was not revised to show continued development of sores and facility interventions. On 6/1/11 at 2:30 p.m., the clinical coordinator/MDS staff member stated she was present during a recent family meeting. Concerns were brought up about the resident's skin and lack of communication. There was a delay in setting up the air mattress for the resident, as it was delivered to the facility but not set up for a couple of days (delivered 4/8 and set up 4/10). The resident was not interviewable. On 7/26/11 at 2:46 p.m., the certified nurse aide (CNA) responsible for caring