Every finding on record at Riverbend Health and Rehabilitation Center

Based on observations and interviews, the facility failed to ensure that food and beverages were stored, distributed, and served in accordance with professional food safety standards in the main kitchen.Specifically, the facility failed to ensure:-The kitchen was kept in a sanitary manner; and,-Condiments were labeled when opened. Findings include:I. Failure to ensure the kitchen was clean and kept in a sanitary mannerA. Professional reference The Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 5/6/26. It revealed in pertinent part, Physical facilities shall be cleaned as often as necessary to keep them clean. Plumbing fixtures such as handwashing sinks, toilets, and urinals shall be cleaned as often as necessary to keep them clean. Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. Floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are smooth and easily cleanable. Refuse, recyclables, and returnables shall be removed from the premises at a frequency that will minimize the development of objectionable odors and other conditions that attract or harbor insects and rodents. Equipment, food-contact surfaces and utensils shall be clean to sight and touch. (Chapter 4, 5, and 6) B. Facility policy and procedureThe Kitchen Sanitation and Cleaning policy, dated August 2023, was provided by the nursing home administrator (NHA) on 4/30/26 at 5:09 p.m. It read in pertinent part, All dietary staff were expected to always use good hygienic practices and to follow all established cleaning and sanitation procedures. Cleaning and sanitation tasks for the kitchen will be outlined in a written cleaning schedule. Cleaning is necessary to protect against microorganisms. Food-contact surfaces shall be cleaned in this sequence: wash with detergent, rinse with clear water, and then use an approved sanitizer. The sanitizer used should be approved for use on food-contact surfaces and must be mixed according to the manufacturer's directions. Cleaning should be performed before, during and after food preparation. Each user must properly clean and sanitize the kitchen after their shift and ensure it is ready for the next user. Tables, stove-tops, oven fronts, dirtied walls, and cooler doors should be washed with hot soapy water, wiped with clean towels, sanitized, and wiped again with clean towels or air-dry.C. ObservationsThe initial kitchen walkthrough was completed on 4/27/26 at 8:55 a.m. The following was observed:-Accumulation of dust on the lower shelf of the tray line table with multiple clean pans and lids nested together directly on the dusty surface.-A rusty pipe extending from the south wall, where an opening in the structure had created a gap between the wall and the pipe. -A ventilation outlet located at the center of the food preparation area was rusted and had visible brown stains present on the air passage surfaces, posing a risk of physical contaminants or debris falling into open food.-A hole was observed on a door frame leading to the kitchen manager's office and the door to the chemical storage room in the kitchen had a missing handle. -The three-compartment sink had white stains and condensation. Underneath the sink was an overflow of dirty cleaning rags in a plastic container.-The ceiling above the kitchen stove had dark yellowish stains spread across the entire surface, directly over the food preparation area.-Missing floor tiles in the dishwashing room.II. Ensured beverages were properly labeled when opened.A. Professional referenceThe Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 5/6/26 read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. (Chapter 3-29).B. Facility policy and procedureThe Food Storage policy, revised May 2025, was provided by the NHA on 4/30/26 at 5:09 p.m. It read in pertinent part. Prepared foods should be used or discarded within seven days. Foods shall be labeled, dated, and covered. Dates used may be a date prepared/opened and/or used by date.C. ObservationsThe initial kitchen walkthrough was completed on 4/27/26 at 8:55 a.m. The following was observed in the walk-in refrigerator:-Two opened Kogi bar-b-que sauces that were not dated;-An opened Caesar salad dressing that was not dated; and,-An opened enchilada sauce that was not dated.III. Staff interviewsThe dietary manager (DM) was interviewed on 4/30/26 at 9:20 a.m. The DM said several work orders had been completed and that the maintenance department was working to repair the broken door handle and replace the missing floor tiles in the dishwashing room. The DM said he did not know why they failed to label the identified items stated above. He said he would immediately update the cleaning schedule to include more days for deep cleaning.Regional resource dietitian #1 and regional resource dietitian #2 were interviewed together on 4/30/26 at 9:35 p.m. Regional resource dietitian #2 said she had updated the kitchen cleaning schedule and would provide education to ensure it was followed. Regional resource dietitian #2 said opened beverages should never be stored undated because they present a safety and quality risk. She said an open beverage with no date makes it impossible to determine whether the product had exceeded its safe shelf life, posing a significant risk of contamination. Regional resource dietitian #1 said the staff should never store food and beverages without proper labeling to prevent contamination. She said they would immediately provide education and monitoring of the kitchen staff.The NHA was interviewed on 4/30/26 at 2:45 p.m. The NHA said she was informed by the regional resource dietitian #2 about the identified sanitary conditions in the kitchen and the kitchen staff's failure to label beverages in the walk-in refrigerator. The NHA said the facility would immediately initiate corrective actions to address all identified food storage and kitchen sanitation concerns.

Based on observations, record review and interviews, the facility failed to prevent misappropriation of property for five (#79, #48, #3, #102 and #51) of five residents reviewed for misappropriation of property out of 51 sample residents.Specifically, the facility failed to prevent the theft of Resident #79, Resident #48, Resident #3, Resident #102 and Resident #51's narcotic medications.Findings include:Record review, observations and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/27/26 to 4/30/26, resulting in the deficiency being cited as past non-compliance with a correction date of 4/22/26.I. Incident of drug diversion on 3/13/26On 3/13/26 at approximately 1:00 p.m. the director of nursing (DON) overheard the nurse on the front east hall in a discussion with Resident #79 about his scheduled narcotic being unavailable. The DON confirmed that there was no narcotic medication available for Resident #79 and the dispensing pharmacy was notified on 3/13/26 about Resident #79's missing medication. The dispensing pharmacy informed the facility that Resident #79's 60 oxycodone pills (two medication cards) were sent to the facility on 3/4/26 and a sufficient supply of the medication should have been available on 3/13/26 for the resident. The dispensing pharmacy provided a new three-day supply of the narcotic medications for Resident #79 on 3/13/26 and the nurse dispensed the resident's narcotic medication from the automated dispensing system until the three-day supply arrived at the facility. Resident #79's pain did not go unresolved on 3/13/26.The DON further reviewed Resident #79's narcotic medication records in order to determine when the resident's last oxycodone medication card had been completed (last medication administered from the medication card) and removed from the medication cart. The DON identified that licensed practical nurse (LPN) #3 had completed Resident #79's oxycodone medication card and removed it from the medication card on 3/12/26, earlier than the card should have been completed.On 3/16/26, the DON expanded the narcotic medications investigation on and found further discrepancies between with the pharmacy's narcotic medications delivery logs and the with facility's narcotic medications logs for Resident #79, Resident #48, Resident #3, Resident #102 and Resident #51.The facility's investigation identified there were approximately 350 to 500 oxycodone and norco narcotic medications that were unaccounted for between 1/7/26 and 3/16/26.II. Facility plan of correctionThe plan of correction the facility put in place in response to the drug diversion incident was provided by the regional clinical resource on 4/30/26 at 5:05 p.m. The plan included the following: A. Immediate action to correct the deficient practiceOn 3/13/26, after learning the pharmacy had sent 60 oxycodone pills for Resident #79, so there should have been pills remaining, the DON investigated the missing narcotics for the resident and identified LPN #3 had completed the resident's oxycodone medication card on 3/12/26, but pills should have still been in the medication card.On 3/13/26 the pharmacy was notified of the concern and sent an additional three-day supply of oxycodone for Resident #79.On 3/13/26 LPN #3 was interviewed by the DON and the NHA and based on that interview, LPN #3 was suspended and sent for a drug test.On 3/16/26 the preliminary drug test results for LPN #3 revealed she tested non-negative for oxycodone and the test was sent to the laboratory for final confirmation of the results.On 3/17/26 the facility terminated LPN #3. On 3/25/26 the final drug testing results confirmed LPN #3 had tested positive for oxycodone. On 4/22/26 the pharmacy consultant conducted a full-house audit of the facility's controlled substances. The narcotics were being stored securely, there were no discrepancies in narcotic medication counts noted, no tampering of medication containers was observed, narcotics were being logged into inventory upon receipt and nursing staff were conducting change of shift counts per policy and regulation. B. Identification of other residentsOn 3/16/26 the DON completed continued investigating and identified further discrepancies between the pharmacy's narcotic medications delivery logs and the facility's narcotic medications logs for Resident #79, Resident #48, Resident #3, Resident #102 and Resident #51. C. Systemic changesOn 3/17/26 education was initiated with the nursing staff. The ongoing education included the new process implemented for the empty narcotic medication bubble packs, education regarding the narcotics logs and education related to signs of drug diversion.The pharmacy consultant would begin reviewing the facility's narcotics and sending the findings to the facility.The pharmacy would only be sending one card of narcotic medication for residents, instead of two cards, each time the prescription was refilled.D. MonitoringThe DON would complete audits to monitor all controlled substances, including comparing the pharmacy narcotics logs to the facility's narcotics logs. Empty narcotics bubble packs would be turned into the DON along with the narcotics log, and then the DON would compare the logs. The audits would be conducted daily until compliance was met.The audits would be discussed in the facility's monthly quality assurance and performance improvement (QAPI) for a minimum of three months.III. Facility policy and procedureThe Drug Diversion and Response policy, revised January 2026, was provided by the regional clinical resource on 4/30/26 at 5:05 p.m. It revealed in pertinent part, Suspicion of drug diversion may arise from a variety of circumstances including, but not limited to:-A witnessed incident of probable drug diversion,-Suspicious activity identified during routine monitoring or proactive surveillance; or,-Self disclosure.Controlled medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-IV), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.Residents have the right to be free from theft and/or misappropriation of personal property.Diversion of medications is defined as using or taking possession of a controlled substance, prescription medication, or medical gas from residents' prescriptions, E-Kit (emergency kit) or secured medication waste devices intentionally without proper authorization or the transfer of a controlled substance from a lawful to an unlawful channel of distribution or use (as adapted from the Uniform Controlled Substance Act - 1994).The Investigating Incidents of Theft and/or Misappropriation of Resident Property policy, revised January 2026, was provided by the regional clinical resource on 4/30/26 at 5:05 p.m. It read in pertinent part, Residents have the right to be free from theft and/or misappropriation of personal property.Train staff to educate them about activities that constitute and procedures for reporting abuse,neglect, exploitation and misappropriation of resident property. IV. Facility investigationThe facility investigation of the misappropriation of residents' narcotics was provided by the nursing home administrator (NHA) on 4/29/26 at 9:00 a.m.The investigation documented that on 3/13/26 at approximately 1:00 p.m. the DON overheard the nurse on the front east hall in a discussion with Resident #79 about his scheduled narcotic being unavailable. The DON confirmed that there was no narcotic medication available for Resident #79 and the dispensing pharmacy was notified on 3/13/26 about Resident #79's missing medication. The investigation documented the dispensing pharmacy informed the facility that 60 oxycodone pills (two medication cards) were sent to the facility on 3/4/26 and a sufficient supply of the medication should have been available on 3/13/26 for the resident. The dispensing pharmacy provided a new three-day supply of the narcotic medication for Resident #79 on 3/13/26 and the nurse dispensed the resident's narcotic medication from the automated dispensing system until the three-day supply arrived at the facility. Resident #79's pain did not go unresolved on 3/13/26. The investigation documented the DON further reviewed Resident #79's narcotic medication records in order to determine when the resident's last oxycodone medication card had been completed and removed from the medication cart. The DON identified that LPN #3 had completed Resident #79's oxycodone medication card and removed it from the medication card on 3/12/26, earlier than the card should have been completed. Upon further investigation, the DON discovered 36 oxycodone 10 milligram (mg) pills were missing from Resident #79's narcotic medication count. LPN #3 was interviewed by the DON on 3/13/26. The investigation identified that the DON had concerns with the information provided by LPN #3 during her interview and discussed her concerns with the NHA on 3/13/26. The NHA and the DON then interviewed LPN #3 a second time on 3/13/26 at approximately 4:25 p.m.The investigation identified that LPN #3 was suspended following the interview and sent by the facility for drug testing. The NHA followed up with the drug testing service on 3/16/26 and was informed LPN #3's drug test results were non-negative for oxycodone and were sent to the laboratory for confirmation of final. The investigation revealed the DON expanded the narcotic medications investigation on 3/16/26 and found further discrepancies between the pharmacy's narcotic medications delivery logs and the facility's narcotic medications logs for Resident #79, Resident #48, Resident #3, Resident #102 and Resident #51. The DON's expansion of the narcotic medications investigation identified there were approximately 350 to 500 oxycodone and norco narcotic medications that were unaccounted for between 1/7/26 and 3/16/26. During the expanded investigation on 3/16/26, the DON identified that LPN #3 received the 60 oxycodone pills (two medication cards) for Resident #79 on 3/4/26 and entered the medications on the facility's narcotic log. However, the pharmacy sent two medication cards of oxycodone for the resident and LPN #3 only logged one card on the facility's narcotic log. Additionally, LPN #3 completed the medication card on 3/12/26 and removed from the medication cart, however, the card should have had six pills remaining when the card was removed from the medication cart.Additional findings during the DON's narcotic medications investigation expansion on 3/16/26 were as follows:The investigation documented LPN #3 completed residents' medication cards and removed them from the facility's narcotic log on 1/7/26, 1/16/26, 1/17/26, 1/29/26, 2/5/26, 2/7/26 (two cards), 2/8/26, 2/12/26 (two cards), 2/19/26, 2/22/26, 2/23/26, 2/27/26, 2/28/26, 3/4/26 (three cards), 3/7/26 and 3/8/26. However, individual narcotics logs could not be located for each of the medication cards.The conclusion of the DON's investigation identified the following residents were missing narcotics:-Resident #79 was missing 36 oxycodone hydrochloride (HCL) 10 mg pills; -Resident #48 was missing 58 oxycodone HCl 5 mg pills;-Resident #3 was missing 130 norco 10-325 mg pills;-Resident #102 was missing 102 oxycodone HCl 5 mg pills; and, -Resident #51 was missing 128 oxycodone HCl 5 mg pills.V. Record reviewAn inservice training document titled Narcotic Logs was provided by the DON on 4/30/26 at approximately 3:00 p.m. The education read in pertinent part,It is the responsibility of all nurses to ensure that all completed narcotics are logged and narcotic bubble packs are attached to narcotic sheets and turned into the DON. The document was signed by 19 combined registered nurses (RN), LPNs and certified nurse aides with medication authority (CNA-Med) on 3/16/26.An inservice training document titled Warning Signs of Drug Diversion was provided by the DON on 4/30/26 at approximately 3:00 p.m. The document was signed by 30 RNs, LPNs and CNAs on 3/16/26.VI. Staff interviewsThe DON, the regional clinical resource and the pharmacy consultant were interviewed together on 4/30/26 at 12:27 p.m.The DON said the facility's investigation of the drug diversion incident began on 3/13/26 when she heard a nurse on the front east hall discussing Resident #79's scheduled narcotic medication being unavailable.The DON and the facility pharmacist consultant said the dispensing pharmacy and the pharmacy consultant were notified of the missing narcotic medications on 3/13/26. The DON said the facility's investigation included narcotic medications log audits, nurse manager and nurse interviews, and interviews of the involved staff. The pharmacy consultant said the investigation revealed the dispensing pharmacy had provided an excess of resident narcotic medication cards at one time, which allowed for easier manipulation of inventory and log count numbers. The DON said the investigation revealed LPN #3 was involved in every narcotic count discrepancy identified during the investigation and this led to the facility concluding LPN #3 was responsible for the missing narcotic medications.The DON said LPN #3 was terminated from employment at the facility. The DON said no residents were harmed when the narcotics were diverted, and no narcotic pain medication administrations were missed. The DON said the drug diversion reported on 3/13/26 was substantiated by the facility.VII. Additional facility follow-up The DON provided additional education that was developed and presented to the nursing staff by the pharmacy consultant on 4/30/26. The documentation was provided by the DON on 4/30/26 at 3:35 p.m. The education was regarding new facility controlled substances processes, including receiving controlled medications and the controlled substance medication count. The education was as follows:The nurse receiving the controlled medications from the dispensing pharmacy should check the pharmacy information for accuracy. The receiving nurse would sign and date the pharmacy shipping manifest if it was accurate. Any discrepancies would be reported immediately to the DON and the dispensing pharmacy. At shift change, or anytime there was a change of responsibility, both off-going and on-coming nurses would complete a controlled medication count. Both off-going and on-coming nurses would visually inspect each controlled substance medication for security and count accuracy. This inspection was to include an examination of each medication for tampering, color, clarity, consistency and expiration date. Failure to inspect each controlled substance medication for accuracy would result in disciplinary action, including termination. Two signatures were needed on the change of shift controlled substance sheet verifying accuracy. The nurses' signatures were verification that each controlled substance medication container and count was accurate with no concerns noted.

Based on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#65) of one resident out of 51 sample residents.Specifically, the facility failed to ensure Resident #65 was assessed for self-administration of Visine eye drops and DeepSea nasal saline.Findings include:I. Facility policy and procedureThe Self Administration of Medications policy, undated, was provided by the nursing home administrator (NHA) on 4/30/26 at 5:09 p.m. It revealed in pertinent part, All residents who desire to self-administer medication may do so if deemed safe by the provider and the facility. The resident must follow all facility policies for self-medication.The facility shall compile a list of all resident medications along with any known allergies and verify the accuracy and completeness of the list with the resident and authorized practitioner at the time of admission.The facility shall review this list with the resident and authorized practitioner at least once a year and maintain documentation of such review.The facility will perform an evaluation of resident's ability to self-administer safely upon admission, quarterly, and with a significant change. An evaluation may also be done if a new medication is ordered or if the staff believes the resident is not administering the medication safely.The facility shall report non-compliance, misuse, or inappropriate use of known medications by a resident who is self-administering to that resident's authorized practitioner and responsible party if applicable.Any resident deemed safe to self-administer medications will have an assessment and a quarterly updated care plan.Failure to administer and/or store medications safely may result in the facility and provider removing the self-administration order.II. Resident #65A. Resident statusResident #65, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included osteoarthritis (chronic joint disease), spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder and muscle weakness.The 3/11/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She required staff supervision for toileting and transfers, moderate assistance with personal hygiene, and set-up assistance with eating.B. Resident observation and interviewOn 4/28/26 at 10:04 a.m. Resident #65 was sitting in her power wheelchair in her room, facing her bed and the bedside drawer. The drawer was partially opened, revealing a bottle of DeepSea nasal saline and a bottle of Visine eye drops inside. Resident #65 said she used the medications by herself, so she kept them in her drawer. She said she used the medications frequently every day but did not remember how many times she used them per day. Resident #65 said the facility staff was aware of the medications in her drawer.C. Record reviewReview of Resident #65's April 2026 electronic medication administration records (EMAR), from 4/1/26 to 4/29/26, revealed no documentation to indicate that the Visine eye drops and the DeepSea nasal saline had been administered to the resident.-However, Resident #65 said she used the Visine eye drops and DeepSea nasal saline every day. (see resident interview above).-Review of Resident #65's electronic medical record (EMR) did not reveal that an assessment for the self-administration of Visine eye drops and DeepSea nasal saline had been completed for the resident.-Review of Resident #65's April 2026 CPO revealed there was no active physician's order for the Visine eye drops and the DeepSea nasal saline.III. Staff interviewsRegistered nurse (RN) #1 was interviewed on 4/30/26 at 9:15 a.m. RN #1 said Visine eye drops and DeepSea nasal saline were medications and required a physician's order to administer. RN #1 said Resident #65 required assessment to deem her safe to administer her own medication before being allowed to have medication in her possession. RN #1 said Resident #65 did not have a physician's order for the Visine and DeepSea nasal saline. RN #1 said she would immediately inform her supervisor and remove the medications from the resident's bedside drawer until it was deemed safe for her to have the medications in her possession.The director of nursing (DON) and the regional clinical resource were interviewed together on 4/30/26 at 10:45 a.m. The DON said Visine eye drops and DeepSea nasal saline were medications and required a physician's order and a resident assessment in order for them to be self-administered and made available to Resident #1 in her bedside drawer. The DON said she was notified by RN #1 of the absence of a physician's order and immediately placed an order for the Visine eye drops and the DeepSea nasal saline. The DON said without an assessment, there was no monitoring for side effects or drug-to-drug interactions The regional clinical resource said all medications should be stored in a secure area, out of reach of all residents, unless otherwise indicated. She said medications kept at residents' bedsides were prone to contamination. She said if a resident touched the tip of a Visine bottle to an infected eye and continued to use it, or if another resident gained access to the bottle, it would create a significant infection control hazard. The regional clinical resource said the facility would immediately provide education to clinical staff to ensure medications were stored in a secure location. She said the facility would ensure all residents' medications had the required physician's orders and safety assessments for self-medication administration.

Based on record review and interviews, the facility failed to provide evidence that a quarterly statement was provided to residents and/or resident representative to establish and maintain a system that assures a full and complete, generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf for one (#65) of one resident reviewed for personal funds out of 51 sample residents.Specifically, the facility failed to provide Resident #65 with a copy of her personal funds statement on at least a quarterly basis.Findings include:I. Facility policy and procedureThe Accounts Receivable policy and procedure, revised 1/1/26, was provided by the nursing home administrator (NHA) on 5/4/26 at 1:12 p.m. It read in pertinent part, This procedure defines the standardized process for managing and monitoring Resident Trust Funds (RTF), ensuring residents have appropriate access to their funds while safeguarding those assets in full compliance with applicable state and federal regulations. It promotes consistency, transparency, and accountability in the administration of resident finances. The facility will send out the RTF statement to the resident or the resident's legal representative within 30 days from the end of the quarter or as specified by the state or in the federal regulations.The business office will keep a copy of the quarterly statements sent to the residents or their legal representatives.The facility's executive director will be responsible for ensuring quarterly statements are submitted in a timely manner and in accordance with State or Federal regulations.II. Resident trust fund authorizationThe Authorization and Agreement to Manage Resident Funds form read in pertinent part, By my signature below, I hereby authorize the facility named above to establish and manage a federal deposit insurance corporation (FDIC) insured interest-bearing resident fund or burial account with the options specified above. I understand that I may have my recurring checks deposited into my resident fund account, that I may make deposits to and withdrawals from my resident fund account at the facility, and that I will receive a statement of any account I have at least quarterly.III. Resident #65A. Resident statusResident #65, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included osteoarthritis (chronic joint disease), spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder and muscle weakness.The 3/11/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. B. Resident interviewResident #65 was interviewed on 4/27/26 at 3:16 p.m. Resident #65 said she was her own financial responsible person, but she said she had never received a statement about her personal funds account since admitting to the facility over a year and a half ago. She said she often went to the business office to ask them verbally whenever she wanted to know her account balance, and the business office manager would verbally tell her the balance. C. Record reviewA request was made on 4/29/26 for documentation to indicate when Resident #65 received her quarterly statements. -However, the business office manager was unable to provide documentation that indicated when Resident #65 received her personal funds account balance statements on a quarterly basis (see interviews below).IV. Staff interviewsThe business office manager was interviewed on 4/29/26 at 2:14 p.m. The business office manager said Resident #65 was her own financially responsible person. She said the resident often stopped by the business office to verbally request her personal funds account balance. The business office manager said she prepared the personal funds account balances of all residents who had a trust account with the facility, but she said she did not send balance statements out to the residents or their representatives. The business office manager said the facility managed the finances for Resident #65 and a personal funds account balance statement should be issued to her at least quarterly. She said she thought the verbal reports she gave to the resident regarding her balance counted, however, she said she did not have documentation of when Resident #65 verbally requested her account balance.The NHA was interviewed on 4/30/26 at 11:20 a.m. The NHA said residents could request a personal funds account balance statement at any time, but it should not replace the policy of issuing quarterly statements and documenting when the statements were issued to residents or sent to their representatives. The NHA said all residents who had money managed by the facility should have received a quarterly personal funds account balance statement, including Resident #65. The NHA said the business office manager should send and document when residents' personal funds account balance statements were issued.

Based on record review and interviews, the facility failed to ensure one (#65) of six residents reviewed for abuse out of 51 sample residents was kept free from abuse.Specifically, the facility failed to protect Resident #65 from verbal abuse by Resident #60.Findings include:I. Facility policy and procedureThe Abuse policy, dated October 2024, was received from the nursing home administrator (NHA) on 4/27/26 at 10:41 a.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property, and exploitation are promptly and thoroughly investigated. When an incident or suspected incident of abuse or neglect is reported, the administrator or designee will investigate the incident with the assistance of appropriate personnel. The investigation will consist of at least the following: an interview with the person(s) reporting the incident; interviews with any witnesses to the incident; an interview with the resident if possible; an interview with staff members having contact with the resident during the period/shift of the alleged incident if applicable; interviews with the resident's roommate, family members, and visitors if applicable; and, a review of all circumstances surrounding the incident. All residents and alleged victims of any pending investigation will be kept safe from any alleged assailants until an outcome of further investigation is achieved. Should the investigation reveal that abuse occurred, the administrator would report such findings to the State Licensing Agency as necessary, health department within 24 hours and police department within two hours as necessary with the results of the completion of the investigation. The administrator or designee will complete a copy of the Resident Abuse Investigation Report form within five working days of the reported incident. II. Incident of verbal abuse towards Resident #65 by Resident #60 reported on 4/7/26A. Facility investigationThe 4/7/26 facility investigation documented a verbal altercation between Resident #60 and Resident #65. The incident occurred on an unknown date in the dining room when Resident #60 passed Resident #65 and called her an inappropriate name. When interviewed by facility staff, Resident #65 said, She just says mean things to me like 'fat (expletive)' when she goes by me. I try to ignore her in the hallways but now she will come real close to me in the dining room and call me names.Resident #60 denied the incident occurred.Five staff members and 11 residents were interviewed. Those interviewed denied having an issue with Resident #60 and had not heard Resident #60 be verbally aggressive towards Resident #65. Staff abuse education was completed with 13 staff members in attendance, but only five staff completed an abuse quiz.Resident #60 was placed on frequent safety checks for three days. The residents' responsible parties, the police and the physicians were notified.The investigation documented that the facility unsubstantiated verbal abuse.-However, abuse occurred due to Resident #60 making willful verbal insults to Resident #65 causing significant emotional distress for Resident #65 (see resident's interview below). B. Resident #60 (assailant)1. Resident statusResident #60, age [AGE], was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar type and cerebrovascular accident (CVA).The 2/24/26 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. Resident #60 denied feeling down, depressed, or hopeless and no behaviors were documented. The MDS assessment indicated the resident received antipsychotic medication on a routine basis.2. Resident interviewResident #60 was interviewed on 4/28/26 at 9:00 a.m. Resident #60 said the incident with Resident #65 happened a few weeks ago in the dining room and she did not remember what she said to Resident #65. She said she and Resident #65 used to have rooms next to each other and they shared a bathroom. She said they had many disagreements back then so Resident #60 moved to a room on another unit. She said she continued to eat her meals in the dining room away from Resident#65. She said she ignored Resident #65 and had not had any further interactions with her.3. Record reviewResident #60's trauma care plan, initiated 9/1/24 and revised 11/22/24, revealed the resident had received counseling in the past but was currently unwilling to participate. Interventions included, when the resident became agitated, intervening before the agitation escalated, guiding the resident away from the source of distress and engaging the resident calmly in conversation.Resident #60's psychosocial care plan, initiated 2/25/26, revealed the resident had the potential for a psychosocial well-being problem related to diagnosis of schizoaffective bipolar disorder and speech and language deficits. Interventions, initiated and revised on 4/27/26 (during the survey), included that social services and activities would continue to monitor and provide emotional support as needed. Triggers included others being in her space.Resident #60's behavior care plan, initiated 9/1/24 and revised 4/12/26, indicated the resident had a history of verbal aggression related to poor impulse control and schizoaffective disorder. Interventions included administering medications as ordered, notifying social services, the NHA, and the physician of increases in behavior, when the resident became agitated, intervening before the agitation escalated, guiding the resident away from the source of distress, engaging the resident calmly in conversation, if the resident's response was aggressive, staff were to walk calmly away and approach later. An intervention indicating triggers of people being in her space was initiated 4/12/26 and revised 4/28/26, during the survey. -The care plan failed to identify the episode of verbal aggression towards Resident #65 that was brought to the facility's attention on 4/7/26 (see facility investigation above) and the interventions implemented to prevent further verbal abuse incidents. A review of Resident #60's electronic medical record (EMR), from 12/1/25 to 4/30/26, failed to reveal documentation of behaviors or verbal aggression. The incident with Resident #65 was not documented in the progress notes, however, Resident #60 had been moved to a different hall in the facility following the incident. Social services progress notes on 4/7/26, 4/10/26 and 4/15/26 indicated Resident #60 said she was not fearful of anyone and stated I don't like some people but I'm not fearful. She refused behavioral health services. C. Resident #65 (victim)1. Resident statusResident #65, age [AGE], was admitted on [DATE]. According to the April 2026 CPO, diagnoses included after care following joint replacement surgery, generalized anxiety disorder, major depressive disorder and morbid severe obesity due to excess calories with a history of bariatric surgery. The 3/11/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15.The MDS assessment indicated the resident did not have any behaviors. The MDS assessment indicated the resident felt down, depressed, or hopeless on seven to 11 days during the assessment look-back period.2. Resident interviewResident #65 was interviewed on 4/27/26 at 3:49 p.m. Resident #65 said there had been a pattern of ongoing verbal abuse from her neighbor, Resident #60, beginning shortly after her admission to the facility. Resident #65 said Resident #60 repeatedly targeted her with derogatory insults, specifically calling her a fat (expletive) which caused her significant emotional distress. She said the repeated incidents made her sad and frustrated, and she felt that no one cared about her. She said she followed proper channels to address the situation. She said she reported the incidents first to staff members and subsequently to social services as the behaviors persisted. Resident #65 said staff assured her an investigation would take place, but she said there had been a lack of follow-up communication and the verbal abuse from Resident #60 had continued unabated. She said it was only after a subsequent report to staff about Resident #60 that the facility took definitive action and transferred Resident #60 to another unit.3. Record reviewResident #65's trauma care plan, initiated 1/29/25 and revised 4/25/25, revealed the resident had a history of verbal abuse from an ex-husband. Triggers included seeing others yelling and swearing. Interventions included approaching the resident in a calm manner, caregivers were to provide opportunities for positive interactions and attention, stopping and talking with the resident when passing by, and encouraging the resident to attend care conferences to express preferences and participate in the care plan process.-The care plan failed to identify the episode of verbal aggression from Resident #60 that was brought to the facility's attention on 4/7/26 (see facility investigation above) and the interventions implemented to prevent further verbal abuse incidents. A review of Resident #65's EMR, from 3/1/226 to 4/30/26, revealed the following;Review of the nursing progress notes revealed no documentation of the incident of verbal abuse by Resident #60.Social service notes, dated 4/7/26 and 4/10/26, indicated Resident #65 said she did not feel unsafe or fearful, but she was frustrated and said, I just stay away from her. On 4/15/26 social services documented Resident #65 again stated she was not fearful and said, I just don't want her to bump into me. III. Additional resident interviewsResident #49 was interviewed on 4/28/26 at 2:55 p.m. Resident #49 said he had heard and witnessed on several occasions Resident #60 calling Resident #65 names and making mean hand gestures towards her. He said this happened in the dining room. Resident #59 was interviewed on 4/28/26 at 4:15 p.m. Resident #59 said she had witnessed on several occasions where Resident #60 called Resident #65 names, such as fat (expletive) in the dining room. IV. Staff InterviewsThe NHA was interviewed on 4/30/26 at 9:00 a.m. The NHA said during Resident #65's care conference on 4/7/26 the resident's representative mentioned the verbal abuse from Resident #60 and Resident #65 verified it. She said the resident's representative and the resident did not indicate when the verbal abuse occurred. The NHA said an abuse investigation was started on 4/7/26.The social services director (SSD) was interviewed on 4/30/26 at 9:09 a.m. The SSD said on 4/7/26 during Resident #65's care conference, the resident's representative said that the resident had mentioned verbal abuse from Resident #60 and Resident #65 verified it, but they did not indicate when it happened. She said after the allegation, the social services department followed up with both residents several times and neither resident was fearful of the other. She said she did not know why the care plans had not been updated to reflect the incident. Certified nurse aide with medication authority (CNA-Med) #1 was interviewed on 4/30/26 at 11:35 a.m. CNA-Med #1 said she had heard Resident #65 complain many times about Resident #60 calling her names and being mean to people in the dining room, but she was uncertain when the incidents occurred. The activity assistant (AA) was interviewed on 4/30/26 at 12:05 p.m. The AA said she had witnessed Resident #60 intentionally running into Resident #65's wheelchair on numerous occasions and calling her names in the dining room. She said she had witnessed Resident #60 being verbally aggressive to male residents in the dining room as well. She said she had reported these incidents to management.Certified nurse aide (CNA) #2 was interviewed on 4/30/26 at 12:40 p.m. CNA #2 said she witnessed the verbal abuse incident a few weeks ago between Resident #60 and Resident #65. She said Resident #60 called Resident #65 a fat (expletive). She said she reported it to management and encouraged Resident #65 to report it as well. The NHA and the regional clinical resource were interviewed together on 4/30/26 at 2:30 p.m. The NHA said based on the facility's investigation of the incident, she did not substantiate the verbal abuse of Resident #65 by Resident #60 because she felt it did not meet the criteria. She said when Resident #65 was initially interviewed, she indicated she was not fearful of Resident #60. The NHA said follow-up with Resident #65 after 4/7/26 continued to indicate she was not fearful and the two residents did not interact. -However, abuse occurred due to Resident #60 making willful verbal insults to Resident #65 causing significant emotional distress for Resident #65 (see resident's interview above). The regional clinical resource said Resident #60 had moved to a different hall in the facility because of prior disagreements with Resident #65 and there had been no further allegations of verbal abuse.

Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#89 and #65) of three residents reviewed for respiratory care out of 51 sample residents. Specifically, the facility failed to:-Ensure that Resident #89 received oxygen therapy in accordance with his physician's orders; and,-Ensure Resident #65's BIPAP (bilevel positive airway pressure, a non-invasive ventilator used to treat breathing difficulties) equipment was maintained in a sanitary manner in accordance with physician's orders.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 11/11/21, accessed on 5/4/26 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 oximetry masks, CPAP (continuous positive airway pressure, BIPAP 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. 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, Storage and Handling policy, revised July 2017, was provided by the nursing home administrator (NHA) on 4/29/26 at 1:10 p.m. It read in pertinent part, It is the policy of this facility to promote resident safety with oxygen administration. The resident's clinical record will include that oxygen is to be administered, when and how often oxygen is to be administered, the type of oxygen device to use, any special procedures or treatment to be administered, charting and documentation related to oxygen use and oxygen concentrators will be maintained in the room when oxygen is ordered. III. Resident #89 A. Resident status Resident #89, age greater than 65, was admitted on [DATE]. According to the April 2026 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypercapnia (excess of carbon dioxide in the blood due to respiratory failure), pulmonary edema, pneumonia, chronic obstructive pulmonary disease and congestive heart failure. The 4/29/26 minimum data set (MDS) assessment identified Resident #89 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment revealed the resident required set-up assistance with eating and was dependent upon staff for showering, dressing and transferring. B. Resident observations and interviews On 4/27/26 at 3:40 p.m. Resident #89 was lying in his bed wearing a nasal cannula (a tubing device that delivers oxygen through the nose) in his nose and connected to a room oxygen concentrator. The oxygen concentrator was set to 4 liters per minute (LPM) of oxygen. Resident #89 said the oxygen was usually set to 3 LPM, however, the nursing staff had turned it up to 4 LPM earlier in the day after his physical therapy. On 4/28/26 at 11:30 a.m. Resident #89 was sitting in his bed wearing the nasal cannula. The oxygen concentrator was set to 4 LPM. Resident #89 said the nursing staff had left his oxygen concentrator on 4 LPM since the previous day. On 4/28/26 at 5:49 p.m. Resident #89 was sitting on the side of his bed eating dinner and wearing the nasal cannula. The resident's oxygen concentrator was set to 4 LPM. Resident #89 said the nursing staff had not changed the oxygen flow rate level since it was increased to 4 LPM (on 4/27/26). On 4/29/26 at 8:25 a.m. Resident #89 was sitting on the side of his bed and wearing the nasal cannula. The resident's oxygen concentrator continued to be set to 4 LPM. C. Record review A review of Resident #89's oxygen therapy care plan, initiated 4/17/26, revealed Resident #89 required oxygen for respiratory failure. Interventions included giving the medications and oxygen as ordered by the physician, monitoring for signs and symptoms of respiratory distress and reporting to the physician as needed, which included respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough pleuritic pain, accessory muscle usage and skin color. A review of Resident #89's April 2026 CPO revealed the following physician's order: Apply oxygen per nasal cannula at 3 LPM continuously, ordered 4/27/26. -However, Resident #89's oxygen flow rate had been set to 4 LPM since 4/27/26 (see resident interviews/observations above). D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/29/26 at 9:28 a.m. LPN #1 said Resident #89's oxygen concentrator was set to 4 LPM. LPN #1 said she reviewed the physician's order, and Resident #89's oxygen order was for 3 LPM. LPN #1 said if the resident's oxygen requirement had increased, the physician should have been notified. LPN #1 said she did not see documentation that a physician was notified when Resident #89's oxygen flow rate was increased to 4 LPM. The director of nursing (DON) and the regional clinical resource were interviewed together on 4/29/26 at 9:39 a.m. The DON said the nurses should have contacted the physician if Resident #89's oxygen requirement had increased. The DON said it was important to contact the physician when oxygen needs changed, as it was a condition change for the resident. IV. Resident #65 A. Resident status Resident #65, age greater than 65, was admitted on [DATE]. According to the April 2026 CPO, diagnoses included osteoarthritis (chronic joint disease), spinal stenosis, hypertension, major depressive disorder, generalized anxiety disorder and muscle weakness. The 3/11/26 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required staff supervision for toileting and transfers, moderate assistance with personal hygiene and set-up assistance with eating. The MDS assessment did not indicate that Resident #65 used a BiPAP machine. B. Observations and resident interviews On 4/27/26 at 10:05 a.m. Resident #65 was sitting in her wheelchair in her room. Resident #65's BiPAP machine was positioned on top of her bedside drawer, next to a gallon of distilled water. The humidifier chamber had a small amount of water in it and condensation was visible on the sides and top of the water chamber. Resident #65 said she cleaned her BiPAP machine by herself every now and then. There was a connecting tube from the BiPAP machine to the mask. The mask was lying across the top of the resident's bedside drawer, with the inside surface of the mask directly touching the top of the bedside drawer. Resident #65 said the BiPAP machine mask had always been sitting on top of her bedside drawer. She said she cleaned it with water and dried it with a paper towel whenever she could. On 4/28/26 at 3:15 p.m. Resident #65 was sitting in her wheelchair facing her bed and her bedside drawer. The BiPAP machine and the tube connecting the machine to the mask were uncovered and lying on top of the resident's bedside drawer. There was visible condensation in the water chamber and the mask was lying uncovered on top of the bedside drawer. Resident #65 said the staff did not clean the BiPAP machine and mask. On 4/29/26 at 8:30 a.m. Resident #65's BiPAP machine was located in the same spot on the resident's bedside dresser. The humidifier's water chamber still had visible condensation and a small amount of water in it. The tube connected to the mask lay uncovered, touching the dresser surface. Resident #65 said the staff did not perform maintenance and cleaning services for her BiPAP machine. Resident #65 said she maintained and performed cleaning of the BiPAP machine whenever she was able to. She said she did not follow a specific schedule. She said she did not know how often to clean her BiPAP machine and was not told to leave the mask to air-dry after cleaning. C. Record review A review of Resident #65's April 2026 CPO revealed the following physician order: Change distilled water in BiPAP and clean BiPAP mask with soap and water, and let it air dry every night shift for maintenance, ordered 9/5/25. -However, according to interviews with Resident #65, the resident performed maintenance cleaning as needed and dried the BiPAP mask with a paper towel (see resident's interview above). Review of Resident #65's respiratory care plan, initiated 9/5/25, revealed the resident required a BiPAP due to risk for reduced pulmonary ventilation and other respiratory complications secondary to central sleep apnea. -The care plan failed to include the physician's ordered maintenance of the BiPAP machine and the mask. D. Staff interviews Registered nurse (RN) #1 was interviewed on 9/30/26 at 9:15 a.m. RN #1 said there was a physician's order to clean Resident #65's BiPAP mask with soap and water each night and allow it to air-dry. RN #1 said there was no documentation in the resident's electronic medical record (EMR) indicating Resident #65's BiPAP mask was cleaned as ordered. RN #1 said to avoid contamination, it was important to follow the physician's maintenance orders for the resident's BiPAP machine and mask. RN #1 said leaving the mask on high-touch areas, cluttered surfaces, and directly on top of bedside drawers exposed it to dust and bacteria. RN #1 said she would immediately inform the DON about the storage and maintenance concerns for Resident #65's BiPAP mask. The DON and the regional clinical resource were interviewed together on 4/30/26 at 10:45 a.m. The DON said it was important to follow the cleaning and maintenance physician's order for Resident #65's BiPAP machine in order to prevent possible respiratory infections and skin integrity issues. The DON said she was informed by RN #1 about the concerns for Resident #65's BiPAP machine and had taken steps to correct the issue. The DON said the current physician's order for the resident's BiPAP cleaning and maintenance was supposed to be completed by the overnight shift each day, not by Resident #65. The DON said an assessment of the resident should be completed with a licensed nurse if Resident #65 preferred to clean her own BiPAP mask in order to promote her independence and also to ensure she was capable of following the physician's maintenance cleaning order. The regional clinical resource said education would be immediately provided to staff to ensure the physician's orders for all BiPAP machines and respiratory equipment were followed to prevent a respiratory infection outbreak. The regional clinical resource said she did not know why the staff failed to ensure Resident #65's BiPAP mask was stored and cleaned appropriately.

Based on observations, record reviews and interviews, the facility failed to ensure proper storage of medications for one of four medication carts and two of three medication storage rooms.Specifically, the facility failed to:-Discard medications that were expired; -Label an inhaler with the date it was opened;-Discard a vial of eye drops for a resident who had been discharged ; and,-Discard undated opened medication tuberculin PPD (purified protein derivative) from a medication storage refrigerator.Findings include:I. Professional referencesAccording to the package insert for Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg (micrograms)/act (actuation inhaler, retrieved on [DATE] from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/204275s012lbl.pdf, Safely throw away Breo Ellipta in the trash six weeks after you open the foil tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the label on the inhaler.According to the manufacturer, Sanofi Pasteur Limited, Product Monograph for Tubersol, [DATE], retrieved on [DATE] from https://www.sanofi.com/assets/countries/canada/docs/products/vaccines/tubersol-en.pdf#:~:text=TUBERSOL%C2%AE%20%5BTuberculin%20Purified%20Protein%20Derivative%20(Mantoux)%5D%20is,of%20tuberculosis%20infection%20(TB)%20in%20persons%20at, A vial of Tubersol which has been entered and in use for 30 days should be discarded.II. Facility policy and procedureThe Medication Access and Storage, E-kit (emergency kit) Access policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 5:29 p.m. It read in pertinent part, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. Any vial without an open date will be discarded immediately, and replaced with a new vial. Any medication that can not be verified as to the expiration date, either due to not being dated when opened, or unclear shelf life, shall be discarded immediately and replaced.III. Observations and staff interviews On [DATE] at 2:34 p.m. the front east medication cart was observed with registered nurse (RN) #2. The following medications were found: -A used Breo Ellipta Inhalation Aerosol Powder Breath Activated 100-25 mcg/act inhaler for Resident #1 which was not labeled with the date it was opened.RN #2 said the inhaler should have been labeled with the date it was opened RN #2 said because there was no opened date on the inhaler, the inhaler should have been removed from the cart and given to the director of nursing (DON) for disposal. -A used floor stock bottle of liquid Delsym Pediatric Cough/12-hour medication with an expiration date of [DATE]. RN #2 said the cough medication should have been discarded on the expiration date of [DATE].-A box of floor stock Rugsby Hemorrhoid Suppositories, with nine of twelve suppositories remaining in the box, with an expiration date of [DATE].RN #2 said the box of suppositories should have been discarded on the expiration date of [DATE].On [DATE] at approximately 3:00 p.m. the front office medication storage refrigerator was observed with the DON. The following medication was found:A bottle of Latanoprost eye drops for Resident #104, who was discharged on [DATE]. The DON said the Latanoprost eye drops should have been removed and discarded when the resident was discharged on [DATE].On [DATE] at 3:15 p.m. the vaccine storage refrigerator was observed with the DON. The following medications were found: -Two opened vials of multi-dose Tubersol, tuberculin PPD 5 TU/0.1 ml (milliliters) vaccine solution which were not labeled with the date the vials were opened.The DON said the Tuberculin vials should have been labeled with the date they were opened and should have been discarded after the 30-day period from the date the vials were opened. The DON said Tuberculin vaccine that was used out of the acceptable date range could be less effective.

Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Menus policy and procedure, revised September 2017, was received from the nursing home administrator (NHA) on 6/27/24 at 12:40 p.m. It read in pertinent part, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu-planning guide. Menu cycles will be developed and tailored to the needs and requirements of the facility. Menu cycles will include standardized recipes. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. II. Resident group interview A group interview was conducted on 6/26/24 at 11:00 a.m. with five alert and oriented residents (#54, #28, #43, #39 and #40), who were interviewable per facility and assessments. The residents regularly attended the resident council meeting. According to the residents, the concerns were brought up in previous resident councils however not resolved. Residents in the group had the following concerns: -Resident #43 said kitchen staff served fruit on the same plate as the meal. Resident #40 agreed. -Resident #43 said the food was served cold and the potatoes were often undercooked. Resident #40 and Resident #39 agreed. -All residents in the group said there was not much variety in the food and it was very bland. -Resident #39 said the eggs were always served cold. III. Additional resident interviews Resident #131 was interviewed on 6/25/24 at 9:14 a.m. Resident #131 said he was on a pureed diet and the food did not taste good. Resident #36 was interviewed on 6/24/24 at 10:50 a.m. Resident #36 said the kitchen often ran out of oatmeal so he received cheerios instead. He said he ate in his room for all his meals and said when his meals arrived they were not hot. He said his meals were always delivered late. He said the cooks did not know how to cook the food right. He said the kitchen often ran out of what they were serving and offered something different than what was on the menu. He said there was no process for staff to take his room tray order. He said he got the main meal delivered to him. He said they offered an alternative menu of about five items, but that menu never changed. He said when meat was served, it was very tough to cut and he was not able to chew it. Resident #23 was interviewed on 6/24/24 at 11:54 a.m. Resident #23 said the quality of the food was poor. Resident #130 was interviewed on 6/24/24 at 1:49 p.m. Resident #130 said the food was very repetitive. He said he got peas three times a week. He said his food was either burnt or not properly cooked. He said one of the pieces of french toast he was served today (6/24/24) was burnt. Resident #68 was interviewed on 6/24/24 at 2:43 p.m. He said the food was dry and tasteless, and the meat was hard to cut with a knife. He said the menus were not offered prior to the meal service and the main menu was not followed. He said residents got whatever the kitchen served and he had just learned to eat whatever they served him because he needed to eat. He said condiments, such as salt or butter, were frequently not provided with meals. IV. Resident council minutes The resident council notes for 1/26/24 documented the group was concerned about the food having been served cold and an unappetizing appearance. -There was no documented follow-up regarding the concerns the residents voiced in the 1/26/24 resident council meeting. The resident council notes for 2/20/24 documented the food was still being served cold. -There was no documented follow-up regarding the concerns the residents voiced in the 2/20/24 resident council meeting. The resident council notes for 3/19/24 documented the food was still being served cold. -There was no documented follow-up regarding the concerns the residents voiced in the 3/19/24 resident council meeting. V. Food committee minutes The food committee meeting minute notes were received from the DS on 6/27/24 at 10:30 a.m. The food committee meeting minute notes from 5/7/24 documented the residents reported the chicken pot pie was not good. The residents said the food was served cold and sometimes warm. -The food committee notes did not document a resolution to the concerns brought up by the residents. The food committee meeting minute notes from 5/21/24 documented the asparagus was overcooked, the meat was overcooked and the chicken was tough. -The food committee notes did not document a resolution to the concerns brought up by the residents. The food committee meeting minute notes from 6/12/24 documented the residents would like more fresh fruit served and bigger portions. -The food committee notes did not document a resolution to the concerns brought up by the residents. VI. Lunch menu for 6/26/24 The facility's posted lunch menu for 6/26/24 read: Encrusted pork loin, braised cabbage, whipped sweet potatoes, dinner roll with margarine, mandarin oranges and coffee. VII. Observations During a continuous observation on 6/26/24, beginning at 10:50 a.m. and ending at 12:58 p.m., the following was observed during the lunch meal preparation and service in the main kitchen. At 11:05 a.m. hot water was boiled on the stove in a metal container and instant mashed potatoes were added and mixed together. The mashed potatoes were at 110 degrees F. At 11:30 a.m. the first plate was served. At 11:43 a.m. the secured unit hot box was ready to be taken to the secured unit. At 11:45 a.m. the main dining room service began. At 12:10 p.m. the dietary supervisor (DS) began plating the next hallway and placed the plates in the hot box. At 12:25 p.m. the hot box was ready to be delivered to the unit. At 12:30 p.m. Resident #68 was served his lunch meal. He received one piece of pork loin (not encrusted), braised cabbage, whipped sweet potatoes, a dinner roll and coffee. -Resident #68 did not receive margarine for his roll. At 12:42 p.m. the braised cabbage ran out so the district manager (DM) warmed up green beans for the vegetable substitute. At 12:45 p.m. the green beans were warmed up. and were at 127 degrees F. At 12:58 p.m. the last plate was placed in the hot box and delivered to the unit. VIII. Test trays Two test trays were evaluated immediately by four surveyors after the last resident had been served their room tray for lunch on 6/26/24 at 1:12 p.m. A. Regular diet test tray The regular diet test tray consisted of pork loin (not encrusted), mashed potatoes with gravy and a dinner roll. -The temperature of the pork loin was 115.5 degrees F. The pork loin was lukewarm, dry and had no flavor. The meat was hard to chew. -The temperature of the mashed potatoes and gravy were 136 degrees F. The mashed potatoes had no flavor and there were no condiments on the tray. -There were no vegetables served on the regular diet test tray. -Margarine was not provided for the dinner roll. B. Pureed diet test tray The pureed diet test tray consisted of pureed pork loin, mashed potatoes and gravy and pureed green beans. -The pork loin was 124.7 degrees F. The pork loin had no flavor. -The mashed potatoes and gravy were 136 degrees F. The mashed potatoes had no flavor and there were no condiments on the tray. -The pureed green beans were 127 degrees F. The green beans had no flavor. IX. Additional record review Grievances from Resident #36 were obtained from the NHA on 6/26/24. One grievance submitted by Resident #36 on 5/8/24 documented that the chicken was not cooked well enough and he could not chew it. The baked potato was not cooked all the way and was hard on one side and soft on the other. The meal calendars were not followed. Ice cream was left out and was always melted. Another grievance from Resident #36 on 5/8/24 documented that the activity calendar was always wrong. The meal on it did not match the menu or what the kitchen cooked. X. Staff interviews The cook was interviewed on 6/26/24 at 12:25 p.m. The cook said for lunch today (6/26/24) she used three cans of sweet potatoes. She said the kitchen ran out of sweet potatoes at 12:25 p.m. She said if the kitchen ran out of food they would find an equal substitute. The cook said the substitute for the sweet potatoes was mashed potatoes. The DS and the DM were interviewed together on 6/26/24 at 2:40 p.m. The DS and the DM said the staff were responsible for putting the condiments on the resident's lunch trays. The DS said the condiments were in a bin next to the kitchen window where the trays were distributed. He said the certified nurse aides (CNA) were responsible for handing out condiments to the residents who preferred to eat in their rooms. The DS said he would make the change and start putting salt and pepper on the trays before they go out. The DS said he was not aware of residents having food complaints. He said if the residents had a concern with the food that the resident's would tell him verbally. He said the facility held a food committee twice a month. He said the food committee started back in April 2024. Certified nurse aide (CNA) #2 was interviewed on 6/26/24 at 5:30 p.m. CNA #2 said all condiments, such as margarine were supposed to be placed on resident meal trays by CNAs prior to delivering the tray to the resident. The DS and the DM were interviewed again on 6/27/24 at 10:15 a.m. The DM said the corporate chefs and the dietitians created the menus for the facility. The DM said they had a four week menu cycle and they changed it two times a year spring to summer and fall to winter. CNA #3 was interviewed on 6/27/24 at 12:40 p.m. CNA #3 said all residents received the main menu dish. She said she did not collect the resident's preferences for the meals. She said when a resident did not like their meal, the resident would tell her and she would pass the message on to the kitchen. She said all resident meal orders were submitted verbally to the kitchen staff. She said if she had five residents who did not want the main dish, she would go to the kitchen five times to report what the resident's preferences were for that meal. The nursing home administrator (NHA) was interviewed on 6/27/24 at 12:55 p.m. The NHA said the food committee met twice a month. She said she was not aware of any food complaints. She said the facility recently implemented a summer menu where they had a chef come in and do cooking demonstrations for the residents. She said they had a chef come in already and the residents really loved it. She said she planned on having the chefs come in more frequently for the residents to try new foods. The NHA said all residents were assessed for meal preferences upon admission and the meals served were based on the resident's preferences. She said if a resident did not like what was being served they could order off the alternative menu. The NHA said the facility used to publish the main menu in the daily chronicles (daily resident newsletter), but they were no longer doing so, as it was not accurately reflecting the menus for residents who were on special diets. She said now the main menu for the day was posted in the dining room. 47960 37166 50315

Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#59) of two residents reviewed for abuse out of 35 sample residents. Specifically, the facility failed to: -Protect Resident #59 from sexual abuse by Resident #62; and, -Implement interventions for Resident #62 in order to prevent the abuse from occurring again. Findings include: I. Facility policy and procedure The Abuse policy was requested from the nursing home administrator (NHA) on 6/25/24 at 3:30 p.m. The Abuse policy was not provided, however, the NHA provided an undated print out titled What is Intimacy? on 6/25/24 at 4:43 p.m. It read in pertinent part, Intimacy can take many forms, from enjoying watching a movie together, to hand holding, to sexual intercourse. Residents have the right to engage in mutually consenting relationships, regardless of their marital status or sexual orientation. It is a protected resident right by statute. When an issue related to the sexual activity of a resident develops, (physical harm, dementia concerns, medical risk, need for medication, problematic pre or post sexual activity behavior, regular violations of others rights to privacy, or public masturbation), it is appropriate to open a care plan problem for that issue. Notation should also be made in the resident's record of educational efforts regarding safe sex practices. This could also include information about the ability of the resident to understand and retain the information and any staff efforts at continuing and tailoring the education to the particular resident's needs. Dementia does not mean that a person no longer has basic needs or wants. Just like a preference for a particular type of dessert, a preference for intimacy can be expressed in a person with dementia long after their orientation and memory has deteriorated. A Form for Intimacy Capacity should be completed as an interdisciplinary team (IDT), as various staff will have different observations and knowledge. If it is determined that residents are not able to consent for intimacy, then a care plan must be in place demonstrating how the facility will keep each resident safe. A resident with dementia and/or cognitive impairment may have the ability to give consent regarding intimacy and sexual activity. People are complex and they change; residents may give consent in one instance and not another, we may complete the Sexual Intimacy Capacity for Consent Assessment multiple times for one resident. II. Facility investigation of sexual abuse incident between Resident #59 and Resident #62 The facility investigation, dated 3/25/24, documented the following information in pertinent part, Resident touched another resident over the pants during a group activity. Interviews were conducted with staff, residents and families. Documentation was reviewed. Resident #59 was assessed following the report of the incident and the resident was at baseline. There was no signs or symptoms of distress or discomfort. There was no treatment provided to the victim. The victim was not transferred to a higher level of care. One resident witnessed the event and stated another resident touched her shoulder but not sexually. There were no concerns from interviews. Conclusion of the internal investigation was unsubstantiated. -However, sexual abuse occurred due to Resident #62 touching Resident #59 in the vaginal area over her pants (see NHA below). Changes were made to the victims treatment regimen and/or care plan as a result of the occurrence: staff to alert leadership if resident expresses distress or discomfort to being touched. Actions were taken with the alleged assailant: medication review requested to ensure no medications influenced sexual behavior. Interventions were put into place to help prevent recurrence: staff education completed to understand intimacy guidelines. -The incident report form was not signed or dated. III. Resident #62 (assailant) A. Resident status Resident #62, age 76, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries (stroke), mixed receptive expressive language disorder, unspecified symptoms and signs involving cognitive functions and awareness and cognitive communication deficit. The 10/16/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required partial/moderate assistance with oral hygiene, toileting, upper body dressing and personal hygiene. He required substantial/maximal assistance with showering/bathing himself, lower body dressing and putting on/taking off footwear. According to the MDS, Resident #62 had no physical behavioral symptoms directed towards others. B. Record review The care plan for other sexual disorder, initiated on 5/10/24 (over one month after the incident with Resident #59), documented Resident #62 was at risk for signs and symptoms of hyper sexuality related to his diagnosis of other sexual disorders. Signs and symptoms included masturbating in public areas and he had expressed interest in women. Interventions included documenting the resident's behavior, administering medications per doctor's orders, encouraging him to cover up when walking back to his room, encouraging him to close his door when needing privacy, reminding him to wash himself when he finished masturbating and when found masturbating in public areas, staff were to remind Resident #62 to masturbate in his room. -The care plan failed to document interventions related to inappropriate touching of female residents. -Review of Resident #62's electronic medical record (EMR) revealed there were no progress notes related to the resident's inappropriate touching incident with Resident #59. Review of Resident #62's June 2024 CPO revealed the following physician's order for monitoring behaviors related to the use of antidepressant medication: Document the number of episodes of the target behavior. Target behaviors: 1. Masturbating in public 2. Interest in women, interventions document in progress notes (PN), ordered 5/29/24. -The physician's order was not obtained until over two months after the incident with Resident #59. IV Resident #59 (victim) A. Resident status Resident #59, age 68, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included bipolar disorder and dementia. The 9/27/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. She required partial/moderate assistance with toileting hygiene, showering/bathing herself and lower body dressing She required set up or clean up assistance with eating and oral hygiene. B. Record review The care plan for cognition, initiated on 2/12/24, documented Resident #59 had impaired cognitive function/dementia or impaired thought processes related to dementia. Resident #59 was alert and oriented to self, able to make basic decisions with assistance if given choices. Her needs were anticipated by staff and she became confused and required redirection and orientation. The resident understood consistent, simple, directive sentences. Interventions included asking yes/no questions in order to determine the resident's needs, communicating with the resident/family/caregivers regarding the resident's capabilities and needs and monitoring/documenting/reporting as needed (PRN) any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness. -Review of Resident #59's EMR revealed there was no progress note related to the incident with Resident #62. V. Staff interviews Registered nurse (RN) #3 was interviewed on 6/25/24 at 3:08 p.m. RN #3 said she heard Resident #62 had an incident where he touched a female resident on the arm. She said she was not aware of Resident #62 touching a female resident on the leg. She said Resident #62 had never been on one to one supervision. She said the facility did not have any resident's who resided on the secure unit who had consented to intimacy. RN #3 said staff stopped any unwanted behaviors or verbally aggressive behaviors before the behaviors could go any further. She said the staff on the unit made sure that no contact was happening between residents because the staff wanted the residents to feel safe and not afraid. She said if there was a resident to resident incident she would notify the nursing manager, management, family and doctor. She said she would have to fill out an incident report and write a note in the resident's chart. RN #3 said Resident #62 was not combative but was hyper-sexual. She said Resident #62 had been displaying sexually inappropriate behaviors since March 2024. She said Resident #62 had been exposing himself and masturbating in the hallway. She said the resident's behaviors were redirectable. RN #3 said the unit nurse manager was responsible for updating the care plans and putting in interventions for residents. Certified nurse aide (CNA) #4 was interviewed on 6/25/24 at 3:25 p.m. CNA #4 said he had never seen Resident #62 display sexually inappropriate behaviors towards female residents. He said he heard Resident #62 had touched a female resident on her leg. He said he heard that the touch was consensual. He said he did not think Resident #62 touching Resident #59 on the leg was inappropriate. CNA #4 said a consent assessment would be done by the RN if further intimacy was agreed upon by both residents. He said he did not know if any residents had filled out an intimacy consent assessment. CNA #4 said a progress note regarding the abuse should have been documented in both of the residents' charts. CNA #4 said Resident #62 had been placed on medications to help decrease his hyper-sexuality. He said he thought the medication had been helpful, as Resident #62 had had a decrease in his behavior of masturbating openly. He said the resident was easily redirectable when masturbating out in the hallway. CNA #4 said Resident #62 had been placed on fifteen minute checks which had been effective. He said staff used a lot of non-pharmacological interventions, such as increasing his activity participation and going outside frequently, to help distract Resident #62. The NHA was interviewed on 6/25/24 at 4:38 p.m. The NHA said both residents were sitting in an activity when Resident #62 reached over and put his hand on Resident #59's vaginal area. She said this was her first experience with a resident being sexually inappropriate. She said if both resident's were deemed consensual then they would not document the sexually inappropriate touch. She said after the investigation, she unsubstantiated the incident. The NHA said Resident #59's consent was based on her interview. The NHA said Resident #59 was interviewed and she said she was okay and said she would not mind if that happened again. The NHA said she did not know if both residents had a history of a relationship prior to the inappropriate touch. She said Resident #59 consenting to the touch should have been documented. The NHA said she did not know if Resident #59 fully understood what had happened with Resident #62. She said as soon as staff saw what happened they stopped it immediately. She said the team was going to work on more assessments from social services and do more through investigations. The NHA said Resident #59 was moved off the unit four days after the sexually inappropriate touch because she no longer benefited from the secure unit. The NHA said Resident #62 had been referred to an all male secure unit at another facility. She said Resident #62 had never displayed any sexually inappropriate behaviors. The NHA was interviewed a second time on 6/26/24 at 4:51 p.m. The NHA said the team, which consisted of the NHA, the director of nursing (DON) and the unit nurse supervisor, initiated a one to one supervision for Resident #62 on 6/25/24 (during the survey). She said they had determined being on fifteen minute checks was not enough for Resident #62 to prevent a further incident of inappropriate touching and felt a one to one supervision would be more appropriate. She said that she was doing education with all the staff on the secure unit. The NHA said Resident #62 had been on the secure unit for a while and there had been no concerns until March 2024. She said she felt like she did the right thing in the moment following the incident. She said she did not substantiate the incident as abuse abuse, but she said she had reported it. The NHA said if Resident #59 had said no, then the abuse would have been substantiated. The NHA said the interdisciplinary team (IDT), which included the NHA, the DON, the unit nurse manager and the social worker would put care plan interventions in place. She said when the incident between Resident #62 and Resident #59 happened, she and the social worker talked about the incident. She said she did not document anything regarding the incident in the residents' charts but reported it to the occurrence reporting portal. RN #4 was interviewed on 6/27/24 at 11:59 a.m. RN #4 said she had never seen Resident #62 touch a female resident. She said, to her knowledge, she had never seen any inappropriate behaviors with Resident #62 and female residents. She said she watched Resident #62 closely. RN #4 said she did not know if Resident #59 could consent to an intimate relationship. She said residents had a right to a relationship but staff would have to consider the residents' cognitive abilities. RN #4 said she had no concerns about the care Resident #62 received. She said staff on the secure unit were very attentive. She said she watched Resident #62 more closely because of the incident that happened in March 2024. RN #4 said any abuse incidents had to be reported to the NHA, the DON and the unit manager. She said she would have to complete a risk assessment form and write a progress note and place the resident on fifteen-minute checks. CNA #5 was interviewed on 6/27/24 at 12:55 p.m. CNA #5 said she had not seen any behavioral changes in Resident #62 after the abuse allegation. She said prior to the abuse incident, both residents had not spent any time together. She said Resident #59 did not communicate well. She said Resident #59 would talk to staff if they asked her a question but she kept to herself. She said Resident #59 did not exhibit any behaviors that would provoke Resident #62. She said Resident #62 had never been aggressive towards staff or residents. CNA #5 said Resident #62 would benefit from an all-male secure unit. She said Resident #62 had not had any other inappropriate behaviors but he did touch his private area when he was out in the hallway. She said Resident #62 had a stroke but he knew what he was doing. CNA #5 said if she witnessed abuse she would report it to the charge nurse or the nurse on the floor and they would take over on what needed to be done. She said she did not have to do any documentation because the nurses were responsible for all of the documentation.

Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 6.25%, or two errors out of 32 opportunities for error. Findings include: I. Facility policy The Medication Administration policy and procedure, revised 2/9/24, was received from the nursing home administrator (NHA) on 6/27/24 at 12:45 p.m. It documented in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Medications are administered in accordance with written orders of the attending physician or physician extender. II. Manufacturer's recommendations According to the National Library of Medicine, Levothyroxine Sodium capsules package insert (2024), retrieved on 7/2/24 from https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=686ba2cf-7651-44de-9b4d-eeaaf2a0e364&audience=professional, Administer Levothyroxine Sodium capsules as a single daily oral dose, on an empty stomach, one-half to one hour before breakfast. III. Resident #49 A. Resident status Resident #49, age 87, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anxiety and hypothyroidism (a condition where the thyroid gland does not produce enough hormones to meet the body's needs). The 4/19/24 minimum data set (MDS) assessment revealed the resident had a cognitive impairment and the brief interview for mental status (BIMS) was not completed. She required no assistance with transfers, walking and personal hygiene. She required supervision for showering. B. Observations On 6/26/24 at 9:15 a.m. licensed practical nurse (LPN) #1 was observed passing medications to residents on the East hallway. LPN #1 prepared medications which included four different tablets and one eye drop for Resident #49. She put all of the tablets, which included a Levothyroxine Sodium (thyroid medication) 100 micrograms (mcg) tablet, into one medication cup and proceeded to Resident #49's room to administer the medications to the resident. Resident #49 was sitting upright in her recliner with her bedside table in front of her. She was eating her breakfast when LPN #1 entered the room. LPN #1 handed Resident #49 the medication cup with the tablets and instructed the resident to take them with water. The resident swallowed the pills and LPN #1 administered the eye drops to the resident before exiting the room. C. Record review Resident #49's June 2024 CPO documented the following physician's order: Levothyroxine Sodium tablet 100 mcg, give one tablet by mouth one time a day for hypothyroidism, give 30 minutes before food on an empty stomach, revised 9/8/23. -However, LPN #1 administered the Levothyroxine Sodium tablet while Resident #49 was already eating her breakfast (see observation above). IV. Resident #14 A. Resident status Resident #14, age 76, was admitted on [DATE]. According to the June 2024 CPO, diagnoses included bipolar disorder and hypothyroidism. The 4/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required maximal assistance with transferring, dressing and showering. B. Observations On 6/26/24 at 9:21 a.m. LPN #1 was observed passing medications to residents on the East hallway. LPN #1 prepared medications which included nine different tablets, one eye drop and a nasal spray for Resident #14. She put all of the tablets, which included a Levothyroxine Sodium 75 mcg tablet, into one medication cup and proceeded to Resident #14's room to administer the medications to the resident. LPN #1 handed the cup of pills to the resident and directed her to take them with water. Resident #14 swallowed the pills andLPN #1 administered the eye drops and nasal spray to the resident before exiting the room. C. Resident Resident #14 was interviewed on 6/26/24 at 9:30 a.m. Resident #14 said she had already eaten breakfast before LPN #1 administered her medications. D. Record review Resident #14's June 2024 CPO documented the following physician's order: Levothyroxine Sodium tablet 75 mcg, give one tablet (75 mcg) by mouth daily before breakfast, take on an empty stomach 30 to 60 minutes before breakfast and other medications, revised 1/16/24. -However, LPN #1 administered the Levothyroxine Sodium tablet after Resident #14 had already eaten her breakfast (see resident interview above). -Additionally, LPN #1 administered the Levothyroxine Sodium tablet with eight other medications (see observation above). V. Staff interviews LPN #1 was interviewed on 6/26/24 at 10:20 a.m. LPN #1 said with the number of residents she needed to pass medications to, she could not get to all of the residents before breakfast. The director of nursing (DON) was interviewed on 6/27/24 at 11:50 a.m. The DON said nursing staff was to follow physician's orders when administering medications.

Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure dispensed medications were administered in a sanitary manner; -Ensure multiple use equipment was sanitized between residents; and, -Ensure environmental service staff followed appropriate hand hygiene practices, ensure high touch areas were cleaned daily. Findings include: I. Professional references The Disinfection of Medical Equipment, updated 5/24/19, retrieved on 2/13/22, from: https://www.cdc.gov/infectioncontrol/guidelines/disinfection/healthcare-equipment.html, documented in part. Equipment; scissors, hemostats, clamps, blood pressure cuffs, stethoscopes should be disinfected with an EPA(Environmental Protection Agency)-registered disinfectant unless the item is visibly contaminated with blood; in that case a tuberculocidal agent (or a disinfectant with specific label claims for HBV and HIV) or a 1:100 dilution of a hypochlorite solution (500-600 ppm free chlorine) should be used. This procedure accomplishes two goals: it removes soil on a regular basis and maintains an environment that is consistent with good patient care. According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 2/13/23 from: http://www.cdc.gov/handhygiene/basics.html (2019), it read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); and after removing gloves (wearing gloves is not enough to prevent the transmission of pathogens in a healthcare settings). According to the environmental cleaning procedures, reviewed 4/21/2020, retrieved on 2/13/22 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, At Least once daily or every 24 hours high touch surfaces are to be cleaned. II. Facility policy The Medication Administration policy, undated, received from the nursing home administrator (NHA) on 2/8/23 at 1:43 p.m. revealed in pertinent part, Medications are administered by a licensed nurse in a manner to prevent contamination or infection. Remove medication from source, taking care not to touch medication with bare hands. The Cleaning and Disinfection of Resident-Care Equipment policy, undated, received from the NHA on 2/9/23 at 4:47 p.m. revealed in pertinent part, resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Multiple-resident use equipment shall be cleaned and disinfected after each use. The Routine Cleaning and Disinfecting policy, undated, received from the NHA on 2/9/23 at 4:59 p.m. reveled in pertinent part, it the policy of the facility to ensure the provisions of routine cleaning and disinfection in order to provide safe, sanitary environment to prevent the development and transmission of infection. Routine surfaces and disinfection will be conducted with detailed focus on visibly soiled surfaces and high touch areas to include: toilet flush handles, tray table, call buttons, tv remote, telephone, toilet seats, sinks, faucets, light switches, door knobs and handrails. Standard precautions will adhere when cleaning any blood or bodily fluid spills; hand hygiene and use of gloves, gown, mask eye protection or face shield. III. Medication not administered in a sanitary manner A. Obsevation On 2/8/23 at 9:55 a.m. registered nurse (RN) #1 was observed dispensing medication on the front hall medication cart. She dispensed two medications from blister packaging directly into her bare hand then transferred pills from her bare hand into a medication cup. RN #1 then went to a resident's room and administered medications. On 2/9/23 at 8:51 a.m. RN #2 was observed dispensing medication on the west hall medication cart. RN #2 was observed dispensing medication from a blister pack directly into her bare hand then into a medication cup. RN #2 dispensed medication from a house stock bottle directly into her bare hand. She dispensed too many medications into her bare hand and returned the un needed tablets back into the house stock bottle after they had touched her bare hand. RN #2 then added the tablet needed for administration into the medication cup with her bare hand. RN #2 then went to administer the medication to a resident. B. Staff interviews RN #1 was interviewed on 2/8/23 at 2:19 p.m. RN # 1 said medication should not be touched by nurses bare hands when being dispensed. Touching medication with bare hands could cause contamination or spread of infection. Licensed practical nurse (LPN) #1 was interviewed on 2/8/23 at 2:29 p.m. LPN #1 said nurses were not to touch medication with their bare hands as it could spread infection or the medication could be harmful to the staff The director of nursing (DON) was interviewed on 2/8/23 at 2:36 p.m. The DON said medications were not to be touched by bare hands at any time as it leads to the spread of infection. III. Multiple use equipment A. Observations On 2/8/23 at 8:39 a.m. RN #1 was observed taking a blood pressure and then holding the blood pressure cuff in her hand returning to the medication cart. She placed the unsanitized blood pressure cuff on top of the cart. -At 8:45 a.m. the blood pressure cuff was sitting on top of the medication cart, and it had not been sanitized as of yet. -At 8:51 a.m. RN #1 left the cart with the blood pressure cuff on the top of the cart, and she went to tend to a resident. Blood pressure cuff remained on the medication cart unsanitized. -At 10:06 a.m. RN #1 was observed exiting a resident room post medication administration with a blood pressure cuff used to take the resident's vital signs with. RN #1 returned to the medication cart and placed an unsanitized blood pressure cuff on the medication cart. RN # 1 sanitized her hands with alcohol based rub and began to prepare the next resident's medication. RN #1 took medications and the unsanitized blood pressure cuff to the next resident's room. RN #1 used the unsanitized blood pressure to measure the resident's blood pressure then administered medication to residents. RN #1 returned to the medication cart with the unsanitized blood pressure cuff and placed it on top of the medication cart and applied hand sanitizer to her hands. -RN #1 failed to sanitize the blood pressure cuff between residents. On 2/9/23 at 11:15 a.m. certified nurse aide (CNA) #1 and #3 were observed transferring a resident with use of the hoyer (mechanical) lift. CNA #1 was observed retrieving the hoyer lift from the storage room. CNA #1 did not sanitize the hoyer lift upon retrieval. She entered resident room with hoyer lift where CNA #2 waited with a resident who was already in a sling. After the hoyer lift was used, CNA #1 asked CNA #4 to return the hoyer lift to the storage area. -The hoyer lift was not sanitized after use for the resident transfer. B. Staff interviews RN #1 was interviewed on 2/8/23 at 2:19 p.m. RN #1 said blood pressure cuffs were to be sanitized between residents. She acknowledged she failed to clean the blood pressure cuff between residents. RN #1 equipment should be sanitized to prevent the spread of infection. CNA #1 was interviewed on 2/9/23 at 1:40 p.m. CNA #1 said blood pressure cuffs and all vitals equipment were to be sanitized between residents. Hoyer lifts were to be wiped down with sanitizing wipes after each use. Sanitizing equipment prevented the spread of infection. CNA #3 was interviewed on 2/9/23 at 1:45p.m. CNA #3 said hoyer lift and vitals sign equipment were to be sanitized between residents to help prevent the spread of infection. CNA #4 was interviewed on 2/9/23 at 2:00 p.m. CNA #4 said hoyer lift and vitals equipment was to be sanitized after every use to prevent the spread of infection. The DON was interviewed on 2/9/23 at 4:39 p.m. The DON said multiple use equipment like blood pressure cuffs and hoyer lifts were to be cleaned between residents to prevent spread of infection. IV. Housekeeping A. Observations On 2/9/23 at 11:45 am. housekeeper (HSK) #1 was observed cleaning a resident's room on the west hall. HSK #1 sanitized their hands with alcohol based hand rub then applied gloves, knocked on the resident's door and announced herself. HSK #1 collected [NAME] from room and bathroom returning to cart in housekeeping cart just outside residents room. HSK#1 collected two rags that were pre soaked in a cleaning solution of Peroxide multi surface cleaner and disinfectant. One rag was placed on top of the bedside table for bed B. A second rag was used to wipe down the night stand from top to bottom, then HSK #1 took the rag placed on the bedside table and wiped down the bedside table including legs. A new rag was used to wipe down armoire in the room from top to bottom. HSK #1 returned to the cart and placed all used rags in the dirty section of the cart. She retrieved the Peroxide multi surface cleaner disinfectant in a spray bottle, entered the resident bathroom and sprayed the sink including facet and the toilet from top to bottom including inside the toilet bowl. She then indicated she had to wait three minutes for the surface disinfectant time. She returned chemical disinfectant to the cart and collected three more rags that were pre soaked in the peroxide multi surface cleaner disinfectant, ringing them out to remove excess liquid and the toilet brush. One towel was used to wipe down all the handrails in the bathroom. After three minutes, a second rag was used to wipe down the facet and the sink using a different side of the rag when touching the facet, the outside of the sink bowl and finally the inside of the sink bowl. She then collected a toilet brush and scrubbed the inside of the toilet bowl. She took the third rag and wiped the toilet from top to bottom including toilet lid and seat to the floor. HSK #1 returned toilet brush and dirty rags to cart. Wearing the same gloves, HSK #1 then collected the broom and swept the bathroom and then the main room sweeping all debris to the entrance of the room. She collected dry debris with a dustpan. She collected the mop stick and three pre soaked mopping pads. The mop pads were rung out to remove excess multi surface cleaner disinfectant above the same clean container they were removed from. One mop pad was used for the bathroom floor, removed and placed in a dirty section of the cart. A second mop pad was used for side B of the resident room and the third mop pad was used to clean side A of the resident room. Dirty mop pads placed into the dirty section of the cart. HSK #1 then removed the gloves from her hands and applied sanitizer to her hands. -HSK#1 failed to disinfect/clean the following high touch areas: door knobs to bathroom and room; call light;and bed control box. -HSK #1 failed to change gloves during the cleaning process. Wearing the same set of gloves from the beginning to end of room cleaning. Contaminating clean disinfectant solutions with touching products with dirty gloves On 2/9/23 at 12:13 p.m. HSK #2 was observed cleaning a resident's room in the west hall. HSK#2 applied hand sanitizer and applied gloves. He knocked and announced himself, entered the room and collected trash from the room and bathroom. HSK #2 collected three pre soaked rags from the peroxide multi surface cleaner and disinfectant bucket and wring them out to remove excess fluid back into the clean bucket. HSK #2 wiped down all the handles to the main room door and bathroom using one rag with a clean section for each handle. He used a second rag to wipe down the bed A's night stand from top to bottom. A third rag was used to wipe down bed B's night stand and TV using a new section of the rag for each new item. HSK #2 returned the dirty rags to the cart, collected the peroxide multi surface cleaner and disinfectant in a spray bottle and the toilet bowl brush housed in a container. He entered the restroom and set the toilet bowl brush on the floor in a container. HSK #2 sprayed the sink inside and out including the faucet, the toilet outside and inside the bowl. Immediately after spraying the toilet, HSK #2 began scrubbing the inside toilet bowl with the toilet brush. He returned the toilet brush to the cleaning cart. Using the same gloves, he removed two pre soaked rags from the peroxide solution, wringing out the excess fluid back into the clean solution. HSK #2 returned to the bathroom and cleaned the sink with one rag from inside the sink bowl to the outside of the sink, then cleaned the faucet using a clean section of the rag as he progressed. He then took the second rag and cleaned the outside of the toilet from top to bottom including the toilet lid and seat using a clean section of the rag for each new area. HSK #2 returned to the cleaning cart with dirty rags placed into the soiled bag. Wearing the same gloves, he collected the broom and dustpan, sweeping the bathroom first and collecting debris then sweeping the main room bringing all debris to the entrance of the room, collected debris in the dustpan. HSK #2 then returned the broom and dustpan to the cart, emptying the dustpan into the trash section on the cart. Using the same gloves he removed three mopping pads from the peroxide multi surface cleanser and disinfectant bucket. He wrung out the excess cleaner back into the bucket he removed the mop pads from. He took the mopping stick and entered the resident room. HSK #2 dropped a mop pad on bed A's side of room, Bed B's side of the room and the third was dropped in the bathroom. HSK #2 started mopping in the bathroom first. He removed the mop pad he used in the bathroom and then mopped bed B's side of the room with the new mop pad, then removed the mop pad. He completed mopping the residents room on bed A's side. He returned the mop handle and all dirty mop pads to the cart. He placed a wet floor sign at the entrance of the room. HSK #2 removed his gloves and applied hand sanitizer to hands. -HSK #2 failed to disinfect the following high touch areas in the residents room: call light; bed control; and bedside table. -HSK #2 failed to change gloves after cleaning the toilet and prior to removing clean rags or mopping pads from clean solution containers/buckets leading to contamination of clean solutions. -HSK #2 failed to allow the disinfectant to sit on the surface for three minutes after spraying the toilet. B. Staff interviews HSK #1 was interviewed on 2/9/23 at 12:04 p.m. HSK #1 acknowledged she did not change gloves when cleaning the residents room and wore the same pair of gloves even after cleaning the toilet. She was unable to identify high touch areas when asked or how often these high touch areas were to be cleaned. HSK #1 acknowledged that she failed to clean the call light, bed control and door knobs to the room and bathroom. HSK #2 was interviewed on 2/9/23 at 12:32 p.m. HSK #2 said high touch areas in the resident rooms were handrails, door knobs, dressing knobs and bedside tables. He said he was unable to clean this resident's bedside table as there was a banana on the table, staff was not allowed to clean the table if there was food present. When asked if he cleaned the call light or the bed function control he acknowledged he did not clean those areas but should have as they were a high touch surface requiring more frequent disinfection or cleaning. HSK #2 said there was no surface disinfectant time when using the Peroxide multi surface cleaner and disinfectant solution which was why he started scrubbing the toilet bowl immediately after spraying it. HSK #2 said he did not change his gloves while cleaning the room since he cleaned from the cleanest to dirtiest areas. The housekeeping supervisor (HSKS) was interviewed on 2/9/23 at 12:37 p.m. The HSKS said high touch areas like: door knobs; bedside tables; call lights; and bed controllers were all considered high touch areas and should be cleaned daily. The HSKS said there was a three minute surface disinfectant time on the peroxide multi surface cleaner. Housekeepers were to change their gloves at the following intervals between bed A and bed B sides of the room, and after cleaning the bathroom with hand sanitization occurring between changing gloves. The HSKS said staff education would be reviewed in order to correct the failures (see observations above).

Based on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment for 14 of 24 out of 57 resident rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms to include rooms #E01, #E08, #E10, #E12, #E16, #W101, #W104, #W105, #W106, #W113, #28, #30, #31 and #32 in a sanitary, safe and comfortable manner. Findings include: I. Facility policy The Safe and Homelike Environment policy, revised 2/1/23, was provided by the nursing home administrator (NHA) on 2/9/23 at 11:32 a.m. The policy revealed the facility would provide a safe, clean, comfortable and homelike environment that allowed the resident to use his or her personal belongings to the extent possible. The facility would also ensure that the resident could receive care and services safely. The facility further ensured that the physical layout of the facility maximized resident independence and did not pose a safety risk. The term environment referred to any area in the facility that was frequented by residents that included (but not limited to) the resident's room, bathroom, hallways, dining area, lobby, outdoor patios, therapy areas and activity areas. The facility staff would report any unresolved environmental concerns to the NHA. II. Performance improvement project (PIP) On 2/9/23 at 12:58 p.m. the NHA provided a PIP plan for the environment of resident rooms that were identified during a mock recertification survey. The baseline measure revealed that resident rooms were to be assessed utilizing the ambassador (a staff person that acts as a representative) visit form, for environmental concerns that would be prioritized based on need. The root causes were the age of the facility, maintenance turnover, new capital expense process, and conflicting priority with the kitchen that needed attention. The obstacles to the PIP were supplies procurement, staffing and ownership transition. The project outcome revealed resident rooms would be comfortable for living and free of environmental hazards. The action items section revealed ambassadors were to audit rooms for prioritization (#8, #10, #30, #101, and #108). The audit start date was 1/23/23 and the completion date was 1/25/23. This audit was completed. The second action item revealed the facility was to complete (make repairs) two rooms each month. This might increase with additional environmental staff and/or resources. The start date was 2/1/23 and a completion date was 12/31/23. The resources that were required included paint, cove base, handles, stain, spackle, flooring, blinds, tools, brushes, furniture, and side tables. III. Resident room observations On 2/6/23 at 10:38 a.m., observations of room #E01 revealed the resident room had a wet and sticky floor at the entrance to the room. The room smelled of urine. There was chipped paint on the room heater cover. On 2/7/23 at 10:34 a.m., observations of room #W106 revealed room cove base had scattered pieces of matter, the corners of the room were unclean with scattered pieces of matter, chipped paint on the entrance door frame, unfinished sheetrock patches in the bathroom, two blue plastic screw anchors in a bathroom wall, chipped paint on the bathroom walls, chipped paint on the bathroom door frames, and a scraped bathroom door. At 10:40 a.m., observations of room #E16 revealed sheetrock damage on a room wall, chipped paint on the bathroom door frame, two window metal blind holders attached to a bathroom wall, six blue screw anchors in one room wall, and chipped paint on the closet drawers. At 10:41 a.m., observatories of room #W105 revealed the corners of the room were unclean with scatter pieces of matter, multiple nails on the room walls, missing room cove base, loose room cove base, chipped paint on the bathroom door frames, missing towel bar in the bathroom, black scrape marks on a bathroom wall, loose entrance door laminate, chipped paint on the room wall corners, six unfinished sheetrock patches on a room wall, five blue plastic screw anchors on a room wall, and chipped paint on the entrance door frame. At 10:47 a.m., observations of room #W104 revealed chipped paint on the bathroom door frame, caulk around the toilet base discolored with matter, the room corners were unclean with scattered matter, loose cove base in the room, and scraped wood on the bathroom door. At 10:48 a.m., observations of room #E12 revealed chipped paint on the bathroom door frame and strong urine odor in the bathroom. At 10:54 a.m., observations of room #W113 revealed loose metal heater cover in the bathroom, scraped bathroom door, chipped paint on the bathroom door frame, and loose metal entrance transition strip. At 11:04 a.m., observations of room #W101 revealed bent metal heater cover in the room, sheetrock damage on one room wall, unsecure linoleum floor by entrance to the room, chipped paint around bathroom sink, loose bathroom grab bar, and missing emergency pull cord in the bathroom. On 2/8/22 at 10:42 a.m., observations of room [ROOM NUMBER] on the secure unit, revealed chipped paint on the entrance door frame, chipped paint on the entrance door, chipped paint on a room wall corner, chipped paint on the bathroom door frame, chipped paint on a bathroom wall, missing toilet paper holder tube, loose bathroom door laminate, dark stain around toilet base, loose caulk around toilet base, chipped paint on the closet drawers, two metal sharp edges on a toilet riser (sharp to touch), and loose metal drawer lock on a dresser. At 10:47 a.m., observations of room [ROOM NUMBER] on the secure unit, revealed chipped paint on the entrance door frame, a loose dresser drawer, chipped paint on the bathroom door frame, chipped paint on the room walls, missing toilet paper holder tube, dark stain around toilet base, chipped paint on the closet drawers, two glass vases sitting on closet shelf, and a loose entrance door handle. At 10:51 a.m., observations of room [ROOM NUMBER] on the secure unit revealed, chipped paint on the entrance door frame, chipped paint on room walls, chipped paint on closet drawers, chipped paint on room wall corners, chipped paint on the bathroom door frame, missing entrance transition strip and chipped paint on the window frame. At 10:54 a.m., observations of room [ROOM NUMBER] on the secure unit revealed, chipped paint on the entrance door, chipped paint on the entrance door frame, chipped paint on the metal heater cover, chipped paint on the closet drawers, chipped paint on the bathroom door frame, one-bathroom light non-functional, one missing towel bar, unfinished bathroom sheetrock patch, and uncleanable red tape on bathroom grab bar. At 11:00 a.m., observations of room #E10 revealed a large hole in the bathroom door, loose caulk around toilet base, chipped paint on the bathroom door frame, two missing towel bars, loose bathroom door laminate, unfinished sheetrock patch on the bathroom wall, torn room floor laminate, chipped paint on the room corner edges, multiple brown stains on room ceiling, chipped paint on the bathroom ceiling, black marks on a bathroom room wall and loose laminate on the entrance door. At 12:04 p.m., observations of room #E08 revealed chipped paint on the entrance door frame, chipped paint on the entrance door, torn room linoleum floor with two small sections missing, brown marks on the room ceiling, chipped paint the room ceiling, one unpainted room wall sheetrock patch, and chipped paint room the wall corners. IV. Staff interviews On 2/9/23 at 11:40 a.m., an environment tour of the facility was conducted with the assistant in training (AIT) and the director of maintenance (DM). The DM said there were 57 resident rooms in the facility. The DM said staff filled out maintenance logs that he reviewed several times each day. The DM said the staff also could call or text him as needed. The DM also said he was in multiple resident rooms during the course of each day. The AIT said the facility did a mock recertification survey and had identified the resident rooms that needed repairs. The AIT said Ambassador Rounds were conducted on 1/23/23 to also identify the rooms that needed repairs. The AIT said the performance improvement plan had a goal of completely repairing at least two rooms per month that took about six hours per room to complete. The AIT and DM observed and documented the above listed observations. On 2/9/23 at 2:13 p.m. the NHA said since the PIP was started, two resident rooms had been deep cleaned and the supplies had been ordered that were necessary for the repairs in resident rooms. The NHA said the PIP goals were to make all of the needed repairs in a minimum of two resident rooms each month. -However, there were safety concerns identified in the resident rooms (see observations above).

Based on observations, record review and interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to have menu extension for the finger food diet, and had repetitive food items for the lacto-ovo-vegetarian (excludes meat except eggs and dairy) diet. Findings include: I. Finger foods Observations during the survey revealed concerns that menu items served to residents with a therapeutic diet of finger foods, were not served finger foods. 2/15/23 noon meal The two residents who had a diet type of finger food diet were served: -meatloaf with ketchup glaze -augratin potatoes -peas 2/16/23 breakfast -oatmeal -cinnamon roll -scrambled eggs 2/16/23 noon meal -chicken thighs with gravy -sweet potato souffle -brussel sprouts -apple cobbler Review of the February 2023 menu failed to show the facility had finger food extensions. The dietary manager (DM) and the regional manager were interviewed on 2/16/23 at 3:00 p.m. The DM confirmed the facility did not have menu extensions for finger food diets. The DM said the facility had only two residents who had that prescribed. The DM said that it was difficult to figure out what to serve as there was no direction. The regional manager confirmed the menus which were generated from the corporate office did not include the finger food diet. The DM agreed oatmeal, sweet potato souffle, au gratin potatoes and vegetables in juice did not constitute finger food items. II. Repetitive menu Observations during the survey revealed concerns that menu items were repetitive for the lacto-ovo-vegetarian diet. 2/6/23 noon meal -The menu called for veggie chicken patty 2/6/23 dinner meal -The menu called for veggie chicken soft taco 2/15/23 noon meal -The menu called for veggie beef patty with gravy 2/15/23 evening meal -The menu called for a veggie beef patty 2/16/23 -The menu called for veggie chicken patty The dietary manager (DM) and the regional manager were interviewed on 2/16/23 at 3:00 p.m. The DM confirmed the menu extensions for the lacto-ovo-vegetarian diet were repetitive. He said the beef veggie patty or the chicken veggie patty were the main items used for the vegetarian diet. The regional manager said she had noticed on 2/15/23 that the beef veggie patty was served for both the noon and dinner meal.

Based on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for four (#26, #27, #41 and #42) of five residents reviewed for immunizations out of 37 sample residents. Specifically, the facility failed to provide the pneumococcal 23-valent polysaccharide vaccine (PPSV23) to Resident #26, #27, #41 and #42. Findings include I. Professional reference According to to the Centers for Disease COntrol (CDC) Adult immunization schedule by age, retrieved on 2/15/23 from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html#note-pneumo, revealed in pertinent part anyone over the age of 65 who have received the PCV13 should receive a dose of PCV20 at least one year after the PCV13 or complete the recommended PPSV23 series. II. Facility policy The Pneumococcal vaccine (series) policy, undated, was received from the nursing home administrator (NHA) on 2/9/23 at 4:39 p.m. It read in pertinent part, it is our policy to offer our residents, staff and volunteer workers immunization against pneumococcal disease in accordance with current CDC guidelines. Each resident will be assessed on admission for pneumococcal immunization. Residents will be offered pneumococcal immunization unless medically contraindicated or the resident already has immunization. Types of pneumococcal vaccines offered will depend upon the recipients age and susceptibility to pneumonia, in accordance with current CDC guidelines. III. Record review A. Resident #26 Resident #26, age 76, admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnosis include bronchopneumonia, chronic obstructive pulmonary disease, and respiratory failure. The 1/13/23 minimum data set (MDS) assessment documented the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The MDS assessment indicated the resident was up to date on pneumococcal vaccine. Immunization record revealed Resident #26 had received Prevnar13 on 12/27/17. -Immunization record failed to show a second dose within a year or completion of Prevnar 23 series. -No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #26 B. Resident #27 Resident #27, age 88, admitted on [DATE]. According to the February 2023 CPO diagnosis include dementia, anxiety disorder, and hypertension. The 10/4/22 MDS assessment documented the resident was severely cognitively impaired with a BIMS score of one out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed Resident #27 received Prevnar 13 on 1/4/18. -The resident's record failed to reveal a second dose or Prevnar 23 series being administered. -No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #27 C. Resident #41 Resident #41, age 83, admitted on [DATE]. According to the January 2023 computerized CPO the diagnosis included dysphagia (difficulty swallowing), cor pulmonale (heart failure), peripheral vascular disease (circulation disorder), acute and chronic respiratory failure (difficulty breathing). The 11/23/22 MDS assessment revealed the resident had a moderately impaired cognition with a BIMS score of ten out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed Resident #41 had received the Prevnar 13 on 12/26/19. -The resident's record failed to reveal a second dose or Prevnar 23 series being administered. -No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #41 D. Resident #42 Resident #42, age 89, admitted on [DATE]. According to the February 2023 CPO diagnosis include chronic kidney disease, congestive heart failure, and bipolar. The 12/22/22 MDS assessment documented the resident moderately impaired cognition with a BIMS score of 11 out of 15. The MDS assessment indicated the pneumococcal vaccine was up to date. Immunization record revealed the resident had received Prevnar 13 on 6/4/15. -The resident's record failed to reveal a second dose or Prevnar 23 series being administered. -No consent or refusal for vaccinations concerning pneumococcal vaccine found in electronic medical record for Resident #42 IV. Staff interviews The director of nursing (DON), the infection preventionist (IP) for the facility, was interviewed on 2/9/23 at 4:39 p.m. The DON said the nursing staff are to review the resident immunizations on the resident's admission and offer vaccines if indicated. The facility was able to offer different types of vaccinations like flu, COVID and pneumococcal if needed. The immunizations had to be ordered by a physician and supply ordered from the pharmacy. The DON reviewed Resident #26, #27, #41 and #42's immunization records and acknowledged that all four residents were missing second doses after receiving Prevnar 13. She was unable to determine if the above residents had been offered pneumococcal vaccinations on admission.

Based on the record review, observations and interviews, the facility failed to promote and maintain resident's dignity for one (#27) of three out of 37 sample residents. Specifically, the facility failed to ensure Resident #27 was offered her breakfast. Findings include: I. Facility policy and procedure The Promoting/Maintaining Dignity During Mealtime policy and procedure,undated was provided by the nursing home administrator (NHA) on 2/9/23 at 3:50 p.m. It documented, in pertinent part, It is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. All staff members involved in providing feeding assistance to residents promote and maintain resident dignity during mealtimes. Resident requests will be honored during meals to the extent possible. Ensure the resident receives the proper tray. Assist resident with opening items, cutting necessary food items, etc. Allow adequate time for resident to complete meal. Do not rush. Allow resident time needed to complete as much as desired of the meal. If resident is in the dining room, assist back to room as needed. If resident is in his/her room, position as resident desires or as directed. II. Resident #27 A. Resident status Resident #27, age 88, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO) diagnoses included anxiety and dementia. According to the 1/20/23 minimum data set (MDS) assessment, the resident was unable to complete the brief interview for mental status (BIMS); however, it showed that she had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. She required one-on-one extensive assistance in activities of daily living including bed mobility and locomotion dressing, and personal hygiene. She required two to one extensive assistance for transfers and toilet use. She required set up assistance for eating. B. Observations On 2/9/23 at 7:20 a.m. the resident was observed lying in bed. She was awake in the bed. -At 7:50 a.m., the tray cart arrived onto the unit. The resident remained in bed. -At 8:06 a.m. the resident continued to be in the bed awake, however she had not been offered her meal. -At 8:43 a.m. certified nurse aide (CNA) #5 threw the residents breakfast meal into the trash. The resident was not offered a breakfast meal. No staff went to the resident's room to check to see if she was awake in bed. Staff took three meal cartons out to be replaced because they were cold. Resident #27 was not included in the three meals being replaced. Resident #27 was not offered a breakfast meal. -At 9:00 a.m. the resident continued to be awake in bed. C. Staff interview CNA #5 was interviewed on 2/9/23 at 8:46 a.m. The CNA confirmed she had thrown the meal away along with her meal ticket. She said the resident did not get up until 10:00 a.m. The CNA said she did not offer the resident a breakfast, but would provide her with a peanut butter and jelly sandwich at a later time. The CNA said she was not aware the resident was awake in bed. The social worker for the secured unit was interviewed on 2/9/23 at approximately 9:00 a.m. The social worker said he was going to go to the kitchen to replace three of the resident meals as the food was cold. He confirmed Resident #27 was still in bed. He said that he did not know why she was not up, as she usually was. He said that Resident #27 was not on the list to replace her meal. He said the resident should be offered her breakfast and allow her to make the choice if she wanted to eat it, or an alternative. The meal should not have been thrown away. The NHA was interviewed on 2/9/23 at 11:52 a.m. The NHA said staff should ask the resident if they would like to eat their meals. She said staff should offer it in bed if the resident did not want to get up. She said the administration would retrain on dignity, activities of daily living and choices.

Based on record review and interviews, the facility failed to ensure the residents' right to make choices about aspects of their lives in the facility that were significant to them for two (#28 and #37) of four out of 37 sample residents. Specifically, the facility failed to provide consistent showers for Residents #28 and #37 according to their preferences and routine shower schedules. Findings include: I. Facility policy and procedures The Routine Resident Care policy, revised September 2011, was provided by the nursing home administrator (NHA) on 2/8/23 at 1:51 p.m. The policy revealed residents were to receive the necessary assistance to maintain good grooming and personal/oral hygiene. The facility would ensure that a resident's capacity for self-performance of these activities did not diminish unless circumstances of the resident's clinical condition demonstrate the decline was unavoidable. Care was to be taken to ensure resident safety at all times. The facility would ensure showers, tub baths, and/or shampoos were scheduled at least twice weekly and more often as needed. II. Resident #28 A. Resident status Resident #28, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included spina bifida (condition affects the spine at birth), anxiety, paraplegia (leg paralysis), depression, muscle wasting and atrophy (wasting). The 10/24/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 15 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident was totally dependent on staff for bathing with a one-person physical assist for bathing. B. Resident interview Resident #28 was interviewed on 2/6/23 at 12:15 p.m. She said she only received one bath a week sometimes. She said she would like at least two baths each week. She said her bath days were Wednesdays and Saturdays. She said she could not get out of bed and she received bed baths. She said bed baths were her choice of bathing. She said not receiving two baths per week made her frustrated. She said a lack of bathing compromised her immune system and at times caused her to develop outbreaks of yeast. C. Record review The care plan, revised 6/30/2020, for activities of daily living (ADLs) self-performance deficit related to spin a bifida with decreased mobility, neurogenic bladder, depression, and anemia. The resident had a risk for musculoskeletal deficits related to spina bifida and non-weight bearing. The pertinent interventions revealed the resident preferred late afternoon baths and required extensive to total assistance with one to two staff for bathing. The November 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident did not receive a bath for the entire month (30 days). The December 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 12/8/22 to 12/14/22 and one bath for the week of the 12/22/22 to 12/31/22. The January 2023 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 1/8/23 to 1/14/23 and two baths for the week of the 1/22/23 to 1/31/23. III. Resident #37 A. Resident status Resident #37, age 93, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, macular degeneration, difficulty in walking, anxiety, depression, muscle wasting and atrophy. The 12/20/22 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15 with no behaviors. The resident required staff supervision for bed mobility, transfers, eating, toileting and personal hygiene. The resident required limited staff assistance for dressing. The resident required physical staff help with transfers with a one-person physical assist for bathing. B. Record review The care plan, revised 6/30/2020, for activities of daily living (ADLs) self-performance deficit related to impaired balance, macular degeneration, incontinence risk, depression, dementia with behaviors, dorsalgia, hearing loss, anxiety, history of facial spasms, hypothyroidism, wears partial dentures, hearing aids, glasses and forgets to wear depends at times. The pertinent intervention revealed the resident required supervision and set up staff assistance with showering, twice a week and as necessary. The November 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident did not receive a bath for the entire month (30 days). The December 2022 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 12/15/22 to the 12/21/22 and one bath for the week of the 12/22/22 to the 12/31/22. The January 2023 Activities of Daily Living documentation survey report for bathing revealed, the resident missed one bath for the week of the 1/1/23 to 1/7/23 and one bath for the week of the 1/15/23 to 1/21/23. IV. Staff interviews The NHA, assistant in training (AIT), director of nursing (DON) and the social services director (SSD) were interviewed on 2/9/23 at 10:06 a.m. They all agreed with the provided documentation for Resident #37. The NHA said Resident #37 was a one staff person physical assist for bathing and at times the resident refused a bath. The NHA said the resident received baths on Wednesdays and Fridays. The NHA said the facility transitioned from the resident computerized documentation system called point click care (PCC) from one ownership company to a second company. The NHA said there were numerous problems with the transition during the month of November 2022. The NHA said many of the custom resident tasks, such as bathing documentation, did not transfer correctly or not at all. The NHA said residents received a bath twice a week or as ordered. The NHA said certified nurse aides (CNAs) should chart if a resident received or refused a bath by at least the end of their shift. The NHA said CNAs could mark that a resident refused a bath in PCC. The DON said if a resident refused a bath, the CNA should ask the resident several more times. The DON said the CNA would tell the nurse of the resident's refusal. The DON said the nurse should ask the resident several times if they wanted a bath, before a refusal was documented in PCC. The NHA, AIT, DON and the SSD were interviewed again on 2/9/23 at 11:13 a.m. They all agreed on the above documentation for Resident #28. The NHA said the resident was a one staff person physical assist for bathing. The NHA said the resident received baths on Wednesdays and Saturdays. CNA #2 was interviewed on 2/9/23 at 1:09 p.m. She said she provided showers/baths for residents. She said she documented it in PCC as soon as she could after the shower was given. She said she could document a refusal in PCC. She said if a resident refused, she would tell the nurse. She said herself or the nurse would go ask the resident multiple times during the shift, if they wanted a shower. She said if they did not want a shower, she would pass the refusal on to the next shift and they would go ask the resident again. CNA #5 was interviewed on 2/9/23 at 1:47 p.m. She said she provided showers/baths to residents. She said she documented in PCC that a shower was given as soon as the shower was completed. She said she was able to mark refusals in PCC. She said if a resident refused, she would ask the resident several more times and then go tell the nurse. She said the nurse would also talk to the resident about getting a shower. She said if the attempts failed, then a refusal was marked in PCC.

Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#20 and #76). Specifically, the facility had a medication error rate of 9.68 percent, which was three errors out of 31 opportunities for error. Findings include I. Professional reference According to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 2/13/23, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. According to the Breztri drug package insert, retrieved on 2/13/23 from: https://den8dhaj6zs0e.cloudfront.net/50fd68b9-106b-4550-b5d0-12b045f8b184/9d44f9af-438a-448b-bb5c-dae506e17e49/9d44f9af-438a-448b-bb5c-dae506e17e49_viewable_rendition__v.pdf dosage and adminsitration after inhalation, rinse mouth with water with out swallowing. II. Facility policy The Medication Administration policy, undated, received from the nursing home administrator (NHA) on 2/8/23 at 1:43 p.m. read in pertinent part, Medications are administered by a licensed nurse in compliance with professional standards of practice. Compare medication source with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time. Refer to a drug reference material if unfamiliar with the medication, including its mechanism of action or common side effects. III. Observations On 2/8/23 at 8:41 a.m. licenced practical nurse (LPN) #1 was observed preparing and administering medications for Resident #76. LPN #1 dispensed two 250 milligrams (mg) tablets of vitamin C and one 50 mg tablet of zinc. -Review of Resident #76 computerized physician orders (CPO) revealed there was no dose indicated for the vitamin C or the zinc. LPN #1 had administered the vitamin C and zinc to Resident #76. On 2/8/23 at 10:32 a.m registered nurse (RN) #1 was observed preparing and administering medications for Resident #20. RN #1 handed Resident #20 a Breztri inhaler (for chronic obstructive pulmonary disease) after shaking inhaler and advised Resident #20 to take only two puffs. Resident #20 administered two puffs of the inhaler and handed inhaler back to RN #1. -Review of Resident #20 CPO revealed an order for Breztri aerosphere aerosol 160-9-4.8 micrograms per inhalation. Administer two puffs inhaled orally two times a day. -RN #1 failed to offer the resident water to rinse mouth after the inhaler was administered. The order failed to indicate the need for the resident's mouth to be rinsed after administration. IV. Staff interviews LPN #1 was interviewed on 8/8/23 at 9:00 a.m. on 2/8/23. LPN #1 acknowledged the order for Resident #76 failed to have a dose ordered for zinc and vitamin C. LPN #1 said she gave 500 mg of vitamin C and 50 mg of zinc because it was ordered for wound care by the wound physician and that was the standard dose the wound physician ordered for everyone who had wounds. LPN #1 said she would get the order clarified. RN#1 was interviewed on 8/8/23 at 2:14 p.m. RN #1 stated she was not aware of the need for the Breztri inhaler requiring a resident to rinse mouth post administration. RN #1 said some inhalers require mouth rinse after inhalation to prevent thrush (oral yeast infection). The director of nursing (DON) was interviewed on 8/8/23 at 2:32 p.m. The DON said all orders must be reviewed for the following prior to administration; name, drug, dose, time and route. She was not aware of the missing dose on the vitamin C and zinc for Resident #76. She was not aware of the need for Resident #41 Breztri inhaler requirement to rinse mouth after the user. She explained there was a risk for thrush for some inhalers that did require a rise after administration. The DON said an education would be completed with nursing staff.

Based on observations, interviews and record review the facility failed to ensure one (#41) of one resident reviewed for dental care out of 37 sample residents received dental services timely. Specifically the facility failed to ensure Resident #41 had a referral sent to a dentist within three days of dentures missing. Finding include: I. Facility policy The Dental Service policy, undated, received from the nursing home administrator (NHA) on 2/9/23 at 4:46 p.m. It read in pertinent part, Facility to assist residents in obtaining routine and emergency dental care. II. Resident #41 A. Resident status Resident #41, age 83, was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO) the diagnosis included dysphagia (difficulty swallowing), cor pulmonale (heart failure), peripheral vascular disease (circulation disorder), acute and chronic respiratory failure (difficulty breathing). According to the minimum data assessment (MDS) dated [DATE] revealed the resident had a moderately impaired cognition with a brief interview of mental for mental status (BIMS) score of ten out of 15. She required extensive two person assistance with bed mobility, dressing, toileting and personal hygiene. She required set up assistance for eating with supervision and cueing. B. Observations and interviews On 2/6/23 at 12:48 a.m. resident was observed wearing no dentures and eating pudding. Resident #41 said her dentures went missing last week and she was struggling to eat her meals which is why I'm eating pudding. She advised staff they were missing and was told they would look for them. She had not heard anything from the staff at this time. Resident #41 said she was worried about her teeth as they were expensive and she did not have the money to replace them. On 2/7/23 at 9:04 a.m. resident was observed in bed with her breakfast tray. She had no dentures in her mouth. Certified nurse aide (CNA) #1 was interviewed on 2/9/23 at 1:40 p.m. CNA #1 said Resident #41 had not had her dentures since last week and noted she had a decrease in appetite. She said Resident #41 had been complaining of gum pain recently and had reported it to the nurse. CNA #1 confirmed resident failed to have dentures at time of interview. The social service director (SSD) was interviewed on 2/9/23 at 3:20 p.m. The SSD said residents were offered ancillary services like dental once a month unless it was an emergent situation then the facility would send them out to a provider in the community. The SSD was unable to provide dental notes for Resident #41's last dental visit. She stated she was not aware of missing dentures until 2/7/23 and she had not made contact with an outside provider which was Resident #41's preference. The SSD was interviewed again on 2/9/23 at 3:55 p.m. she said she was able to obtain a dental visit for Resident #41 after the initial interview (see above) on 2/21/23. She was not able to say what the facility would be doing to aid Resident #41 until her dental appointment. C. Record review Resident #41 medical record reviewed on 2/7/23 at 3:30 p.m. it failed to reveal: -Any documentation on when the resident last saw a dentist. -There were no progress notes in the social service section indicating knowledge of dentures missing. -There were no nursing progress notes indicating that the resident was having issues with eating related to mouth or denture concerns. On 2/9/23 at 10:28 a.m. the NHA provided a grievance form dated 2/6/23 where the resident had indicated that she was missing her dentures. The action taken according to the grievance form was the social worker had attempted to search the Resident #41's room. Resident #41 became agitated and stated she lost them at the last place. The social worker called the eye center the resident had visited on 2/3/23 but no dentures had been turned into the eye center. Social worker stated this was the last place other then the nursing facility resident #41 had been to. III. Additional information The NHA on 2/13/23 at 1:18 p.m. provided a social service note effective date 2/9/23 at 7:21 p.m. documenting the following in part, social worker was notified on 2/7/23 that Resident #41 were missing dentures. She attempted to search Resident #41 room but the resident became agitated saying 'they are not here, I lost them at the other place.' Resident was unable to say where the other place was. Resident had recently had an appointment with an eye center. Center was called with no results in dentures located. Resident #41 dental offices of choice were contacted and an appointment was scheduled for 2/21/23. -However, the follow up was not done until identified during the survey, when the resident had been missing her dentures during the observations (see above) and had reported to the care staff.

Based on interviews and record review, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for one (#75) of two out of 39 sample residents. Resident #75 admitted to the facility with a left [CONDITION(S)], required extensive staff assistance for toileting, transfers and bed mobility. The resident was identified as being at moderate risk for developing pressure ulcers at admission. Subsequently, Resident #75 acquired an unstageable deep tissue injury to the left buttock (9/30/21), an unstageable deep tissue injury to the right buttock (9/30/21) and an unstageable deep tissue injury to the sacrum (9/30/21). The facility failed to implement an air mattress (10/14/21) as an intervention, until after 10/14/21, when she had developed three pressure ulcers. Furthermore, after the air mattress was in place, the resident acquired an unstageable deep tissue injury to the left distal posterior calf (10/21/21) and an unstageable deep tissue injury to the left posterior lateral heel (10/21/21). Findings include: 1. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from http://www.npuap.org (11/11/21): Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [CONDITION(S)] of intact skin. Intact skin with a localized area of non-blanchable [CONDITION(S)], which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). II. Facility policy and procedures The Pressure Injury Prevention and Management policy, copyright 2020, was provided by the nursing home administration (NHA) on 11/2/21 at 12:50 a.m. The policy revealed the facility was committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. The term pressure ulcer/injury referred to localized damage to the skin and/or underlying soft tissue over a bony prominence or related to a medical or other device. The facility should establish and utilize a systematic approach for pressure injury prevention and management. This included prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions and modifying the interventions as appropriate. After the completion of a thorough assessment/evaluation, the interdisciplinary team would develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions would be based on specific factors identified in the risk assessment, skin assessment and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging and wound characteristics). Evidence based interventions for prevention would be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions included, but were not limited to: redistribution of pressure (such as repositioning, protecting and/or off-loading of heels, etc.); minimize exposure to moisture and keep the skin clean, especially of fecal contamination; provide the appropriate pressure-redistributing support surfaces; and maintain or improve nutrition and hydration status where feasible II. Resident status Resident #75, age 95, was admitted on [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/14/21 minimum data set (MDS) revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident did not have any behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was at risk for the development of pressure ulcers. The resident had one or more unhealed pressure ulcers/injuries. The resident had three unstageable deep tissue injuries. III. Record review The Admission Data Collection note dated 9/22/21 at 5:06 p.m., revealed the resident did not have any pressure ulcers. The resident did have a non-pressure ulcer surgical skin incision at the left trochanteric hip. The Admission Note dated 9/22/21 at 5:41 p.m., by a licensed practical nurse (LPN) revealed the resident arrived in the facility at 3:00 p.m., by an in-house transport. The resident had a status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Active ranges of motion were performed on all extremities; except for the left lower extremity. Quarantine procedures were explained and the resident verbalized understanding. The Braden Scale for Predicting Pressure Sore Risk dated 9/22/21 at 2:17 p.m., revealed a score of 13 or moderate risk. The resident was very limited and responded only to painful stimuli. The resident could not communicate discomfort except by moaning or restlessness and/or the resident had sensory impairment which limited the ability to feel pain or discomfort over half of the body. The resident had occasionally moist skin and required an extra linen change approximately once a day. The resident was chair fast and the ability to walk was severely limited or non-existent. The resident was unable to support her own weight and/or must be assisted into a chair or wheelchair. The resident was limited and made occasional slight changes in her body or extremity position but was unable to make frequent or significant changes independently. The resident rarely ate a complete meal and generally ate only about half of the food offered to her. One of the potential problems was during movement her skin probably slid to some extent against the sheets, chair or other devices. A Behavior Note dated 9/23/21 at 1:50 a.m., by a registered nurse (RN) revealed the resident woke up this night confused and angry. This nurse explained that she came from the hospital with a hip repair and she would be staying at the facility for rehabilitation. The Head to Toe Skin Check dated 9/23/21 at 2:17 p.m., revealed the resident had a surgical incision to the left trochanter with a clean/dry/intact dressing. A Nursing Daily Skilled Charting note dated 9/24/21 at 1:20 p.m., revealed the resident had a surgical incision site to the left hip. The Baseline Care Plan dated 9/24/21 at 2:00 p.m., revealed the resident did not have any pressure ulcers. A Nursing Daily Skilled Charting note dated 9/25/21 at 12:45 p.m., revealed the resident had a surgical incision site to the left hip. The Bowel and Bladder assessment dated [DATE] at 2:17 p.m., by an LPN revealed the resident was incontinent of urine at all times. The resident had a bowel movement every three or four days. A Nursing Daily Skilled Charting note dated 9/26/21 at 1:36 p.m., revealed the resident had a surgical incision site to the left hip. A Care Conference Note dated 9/27/21 at 2:44 p.m., revealed the resident was already showing improvement in her mobility. The resident was willing to work with therapy and seemed motivated to meet her goals and return home. The resident would continue to receive physical therapy and occupational therapy. The care plan, created on 9/27/21, revealed the resident had the potential for impairment of the skin integrity related to the use of aspirin therapy, anticoagulant therapy, incontinence and limited mobility. Some of the interventions included for the resident to avoid scratching, keep the resident's fingernails short, keep hands and body parts from excessive moisture. Staff were to keep the resident's skin clean and dry: use lotion on dry skin. Encourage good nutrition and hydration to promote healthier skin. Staff were to follow facility protocols for treatments of injury. Interdisciplinary team referrals as indicated for physical therapy services and for nutritional services. Resident to utilize a pressure reducing mattress. Staff were to provide incontinence care after each incontinent episode or according to the established toileting plan. Staff were to provide treatments as ordered. Staff were to perform and document weekly skin checks. The care plan, created on 9/27/21, revealed the resident was at risk for pressure ulcer development related to slightly limited sensory perception, occasionally moist, chair fast, limited mobility, and the potential for friction/shear. The resident did not call for staff assistance for positioning or care when in bed. The resident rejected care from staff at times with repositioning and ordered treatments for skin. Some of the interventions were: To administer medications as ordered and observe for effectiveness. Complete a weekly full body check and document. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Encourage and offer frequent repositioning and turning. Offload the resident's bilateral heels at all times while in bed initiated on 10/2/21. Application of an air mattress initiated on 10/14/21. Despite staff education, the resident often refused and/or would accept repositioning by staff and then turn herself back to the original position initiated on 10/27/21. Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan created on 10/2/21, revealed the resident had the potential of pressure ulcer development related to immobility. Some of the interventions were to administer medications as ordered and observe for effectiveness. Complete a weekly full body check and document. Provide incontinence care after each incontinence episode, or according to the established toileting plan. Interdisciplinary team referrals as indicated to registered dietitian, physical therapy and occupational therapy. The care plan, created on 10/2/21, revealed the resident had an unstageable deep tissue injury of the left buttock on 10/14/21, an unstageable deep tissue injury of the right buttock on 10/14/21, an unstageable deep tissue injury of the left buttock now extending into the sacral region on 10/21/21, and an unstageable deep tissue injury of the left buttock now split and categorized into three separate wounds: (1) left buttock, (2) right buttock and (3) sacrum. Some of the interventions were to daily monitor the wound and surrounding tissues for any negative changes and/or abnormalities. Wound physician to routinely follow. Encourage and offer frequent repositioning and turning. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide incontinence care to the resident after each incontinence episode, or per established toileting plan. Application of an air mattress and gel chair cushion initiated on 10/14/21. Despite staff education, the resident often refused and/or would accept repositioning by staff and then turn herself back to the original position initiated on 10/27/21. The care plan, created on 10/2/21, revealed the resident had an unstageable deep tissue injury of right heel. The resident had an unstageable deep tissue injury of the left distal posterior calf on 10/21/21 and an unstageable deep tissue injury of the left posterior lateral heel on 10/21/21. Some of the interventions were for daily monitoring of wound and surrounding tissues for any negative changes and/or abnormalities, wound physician to routinely follow, encourage and offer frequent repositioning and turning. Staff were to offload the resident's bilateral heels at all times while in bed. Observe/document location, size, treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Provide wound care per physician orders. Obtain and observe lab/diagnostic work as ordered, report results to physician and follow up as indicated. Encourage good nutrition and hydration in order to promote healthier skin. Despite education, the resident often refused and/or will accept repositioning and then turn herself back to her previous position. Staff were to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physical Therapy progress note for services from 9/23/21 to 10/6/21 revealed the resident received skilled services for bed mobility. This was electronically signed by a doctor of physical therapy on 10/6/21 at 3:31 p.m. The Physical Therapy encounter note electronically signed by a physical therapy assistant on 9/27/21 at 1:46 p.m., revealed the resident received therapy for transfer training with emphasis on bed mobility with resident at total dependence on supine to side lying. The Physical Therapy encounter note electronically signed by a doctor of physical therapy dated 9/28/21 at 2:42 p.m., revealed therapy services to facilitate upright sitting at the edge of the bed for improved activity tolerance and core strength. The resident maintained position with intermittent upper extremity support for 15 minutes. The Physical Therapy encounter note dated 9/29/21 was electronically signed by a doctor of physical therapy dated 9/30/21 at 8:28 a.m., revealed therapy provided bed mobility training which included rolling in bilateral directions. The resident required maximum assistance to complete the activity and complained of pain in the left hip. The resident tolerated multiple repetitions and demonstrated increased participation throughout trials. The resident received sit to supine training with elevated head of the bed and the resident demonstrated improved initiation and participation with hip abduction/adduction and continued to require maximum assistance to complete the activity. The Physical Therapy encounter note dated 9/30/21 was electronically signed by a doctor of physical therapy dated 9/30/21 at 3:45 p.m., revealed the resident received instructions on seated lower extremity strengthening in all planes. The resident received bed mobility training and the resident continued to exhibit improved performance with hip abduction/adduction. The Admission Nutrition Data Collection dated 9/30/21 at 10:09 a.m., revealed the resident was alert and verbal. The resident had a surgical wound of the left hip and no history of pressure ulcers and no current pressure ulcers. The resident utilized a regular diet and texture with a 25 to 75% meal intake. Recommendation for a house supplement shake twice a day for added nutrition for her variable intakes. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/2/21 at 4:09 p.m., revealed the resident received bed mobility training. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/2/21 at 4:09 p.m., revealed the resident was provided seated balance training with the resident tolerating edge of bed position with intermittent upper extremity assist for 15-minutes. The resident was provided mobility training with rolling right and left. The resident did not tolerate a complete roll to the right due to pain. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/7/21 at 8:37 a.m., revealed staff facilitated bed mobility training with emphasis on rolling to increase resident participation in caregiving activities. The resident required maximum assistance and was resistant to complete left side lying due to pain. The resident received bed mobility training and required maximum assistance to complete supine to sitting with the head of the bed elevated. A Physical Therapy encounter note dated was electronically signed by a doctor of physical therapy dated 10/7/21 at 5:19 p.m., revealed therapy for supine ranges of motion to bilateral lower extremities in order to improve joint and muscular integrity. Also, therapy for bed mobility training for rolling with moderate assistance; supine to sitting with moderate assistance of two staff with additional time required. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/8/21 at 4:08 p.m., revealed the resident was provided therapy for bed mobility from sit to supine with maximum assistance for guiding trunk and for bringing lower extremities onto the bed. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/11/21 at 5:28 p.m., revealed the resident received therapy for bed mobility with moderate assistance of two staff scooting to the edge of the bed. The resident was also a moderate assist with proper positioning and scooting back for improved comfort and safety in a wheelchair. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/12/21 at 4:45 p.m., revealed the resident had an open wound to the right lateral heel; nursing staff was notified and would attend to the wound. The encounter was for bed mobility and positioning with maximum assistance; the resident tended to resist, which was likely due to pain. The nursing staff were educated to utilize a mechanical lift at this time for safe transfers. Also, provided instructions that the resident should be up in a wheelchair daily, to optimize healing and reduce the risk of decline. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/13/21 at 4:06 p.m., revealed the resident was positioned in bed with heels floated. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/14/21 at 3:48 p.m., revealed the resident provided bed mobility training for rolling with moderate assist. Positioning strategies were provided for improving comfort and safety in a wheelchair with bilateral feet supported to reduce the risk of falling forward. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/15/21 at 3:14 p.m., revealed the resident was assessed for the current seating system for appropriate modifications. A Physical Therapy encounter note electronically signed by a doctor of physical therapy on 10/19/21 at 3:35 p.m., revealed bed mobility training was provided with the resident requiring maximum assistance to complete rolling right and left. The resident expressed pain with the activity. There was no pain at sitting on the edge of the bed with supervision assistance. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/20/21 at 2:55 p.m., revealed diathermy applied to the right heel for 30-minutes in order to facilitate circulation, increase blood flow/circulation and minimize negative effects of immobility with intensity/setting at variable. The Occupational Therapy encounter note dated 10/19/21 electronically signed by an occupational therapist dated 10/25/21 at 3:31 p.m., revealed diathermy applied to the left heel for 30-minutes in order to increase blood flow/circulation and facilitate circulation with intensity level/setting at variable. The resident was provided with safety training during functional mobility. The resident was also provided with facilitation of neuromuscular functional [MEDICATION(S)] patterns to improve mobility, postural control, techniques to facilitate proprioception and techniques to facilitate motor control in order to facilitate motor control. The resident was further provided safety training during functional mobility. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/21/21 at 3:31 p.m., revealed therapeutic activities were provided for positioning related to skin integrity, modification to seating for skin integrity (including application of biomorphic equagel cushion). A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/21/21 at 4:54 p.m., revealed the resident received bed mobility training for improvement of the resident's position with a maximum assistance of two staff for rolling and scooting up to the head of the bed. Positioning strategies were also provided to reduce the risk for impaired skin integrity. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/21/21 at 5:08 p.m., revealed the resident was provided short wave diathermy to bilateral heels for increased circulation, [CONDITION(S)], skin integrity and pain modulation. The resident also received modification to her seating surface for improved skin integrity while seated. The resident now has a 20-inch (tall) thickness equagel with sacral depression affixed for consistency of placement. A Physical Therapy encounter note electronically signed by a physical therapist assistant on 10/22/21 at 4:56 p.m., revealed the resident received bilateral ankle ranges of motion for improvement of joint flexibility and [CONDITION(S)] reduction. The resident was positioned for comfort with heels suspended to avoid pressure. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/22/21 at 2:48 p.m., revealed diathermy was applied to the right heel for 30-minutes to facilitate circulation and increased circulation for wound healing with intensity level/setting at variable. The resident received therapy for postural control techniques to facilitate motor control, facilitation of patterned movements and techniques to facilitate proprioception in order to facilitate neuromuscular functional [MEDICATION(S)] patterns to improve mobility and facilitate neuromuscular functional [MEDICATION(S)] patterns to improve self-care. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/25/21 at 4:03 p.m., revealed short wave diathermy to bilateral heels for increased circulation, [CONDITION(S)] and pain modulation on variable setting. Also, analysis/adjustment of wheelchair seating/positioning, facilitation of position in space, postural control and proper body alignment while sitting and supine. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/26/21 at 4:46 p.m., revealed short wave diathermy to bilateral heels for increased circulation, pain modulation at variable setting. The resident provided an anticipatory reaction challenge: weight shifter lateral, weight shifted anterior and trunk rotation in sitting unsupported for one repetition. A Physical Therapy encounter note electronically signed by a physical therapy assistant on 10/28/21 at 3:48 p.m., revealed the resident participated in lower extremity ranges of motion for improving joint flexibility and circulation to musculature in order to improve the resident's tolerance for moving lower extremities during functional tasks. The resident also participated in positioning strategies in a wheelchair for improving comfort and safety. Also, lower extremity positioning on leg rest for improved alignment and reduced pressure to both heels. The Occupational Therapy encounter note electronically signed by an occupational therapist dated 10/29/21 at 1:30 p.m., revealed provided facilitation of neuromuscular functional [MEDICATION(S)] patterns to improve self-care tasks, techniques to facilitate motor control, proprioceptive techniques to improve safety, decrease fall risk in order to have increased movement and safety with self-care tasks. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Occupational Therapy encounter note electronically signed by an occupational therapist dated 11/1/21 at 5:08 p.m., revealed the resident was provided standing balance with assistance of two staff to optimize ability to stand and transfer for opportunity to return home. A. Pressure injury of right posterior heel A Head to Toe Skin Check dated 9/29/21 at 11:49 a.m., revealed a facility acquired blister/deep tissue injury to the right heel measuring 5.5 centimeters (cm) x 4.0 cm x 00. This was a fluid filled blister. The Head to Toe Skin Check dated 9/29/21 at 11:49 a.m., revealed a facility acquired blister/deep tissue injury to the right heel measuring 5.5 cm, 4.0 cm x 00 with an intact fluid filled blister. The eInteract Situation, Background, Assessment and Recommendation (SBAR) for Providers dated 9/29/21 at 11:49 a.m., revealed a change in condition was reported, related to a skin wound or ulcer. The skin status evaluation revealed a blister. The nursing observations, evaluation and recommendations revealed a pressure related deep tissue injury. The primary care provider feedback recommendations were for a wound care consultation, and the resident's physician would evaluate the resident tomorrow. The Interdisciplinary Team (IDT) note dated 9/29/21 at 12:30 p.m., by an LPN revealed the resident had a left hip surgical site skin impairment and scored a 15 on the Braden Scale, indicating the resident was at risk for development of a pressure ulcer. A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Document + or -. (+) = no observed abnormalities or changes to the dressing, skin, or pain associated with the wound. Document (-) = abnormalities or changes to the dressing, skin, or pain associated with the wound are present. If any abnormalities were observed, document in progress note every shift. every shift for monitoring. The Skin Weekly Pressure Ulcer Record dated 9/30/21 at 2:28 p.m., revealed an unstageable deep tissue injury to the right posterior heel measuring 4.5 cm x 5.5 cm x nm (no measurement). The surface area was 24.75 cm (squared) with a wound bed that was a purplish blister. Provider to evaluate and treat; wound care treatment and continue monitoring. The Initial Wound Evaluation and Management Summary dated 9/30/21 by the wound physician revealed unstageable deep tissue injury of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm. The surface area measured 24.75 cm (squared). There was no exudate. The plan of care was to off load the wound. The treatment plan was for skin preparation twice a day for 30 days. The Wound Evaluation and Management Summary dated 10/7/21 by the wound physician revealed unstageable deep tissue injury of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm with no exudate. The surface area measured 24.75 cm (squared). The plan of care was to off load the wound. The treatment plan was to apply skin preparation twice daily for 23 days. The Skin Weekly Pressure Ulcer Record dated 10/14/21 at 1:30 p.m., revealed an unstageable deep tissue injury to the right posterior heel measuring 4.5 cm x 5.5 cm x nm with an onset date of 9/29/21. The surface area measured 24.75 cm (squared): blister. Provide pillows, wedges and wound care treatment with monitoring. Discontinue the current order. Apply [MEDICATION(S)] (antiseptic) twice a day, cover with an ABD (highly absorbent dressing) and secure with Kerlix (bandage roll). The Wound Evaluation and Management Summary dated 10/14/21 by the wound physician revealed an unstageable deep tissue wound of the right posterior heel with partial thickness. The wound measured 4.5 cm x 5.5 cm x nm with no exudate. The surface area was 24.74 cm (squared). The plan of care was to off load the wound. The treatment plan was for the primary dressing to use [MEDICATION(S)] and apply twice daily for 30 days. The secondary dressing was an ABD pad applied twice daily for 30 days and a gauze roll (Kerlix) 2.25 inches: apply twice daily f

Based on record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#84 and #33) of six residents out of 39 total sample residents. Resident #84 with diagnosis of Alzheimer's disease was admitted to the facility with a known fall risk. The resident had an unwitnessed fall on 9/20/21 in which he sustained a skin tear and had left hip pain. The intervention for the fall was to move the resident closer to the nurse's station for better visual observation. The resident was not moved closer to the nurse's station due to COVID-19 isolation protocols. However, the facility did not implement increased supervision after the fall that occurred on 9/20/21. Due to the facility's failures, the resident had an unwitnessed fall on 9/23/21, where he sustained a fractured right hip and a fractured right elbow. In addition, the facility failed to ensure thorough neurological assessments were completed for Resident #33 after an unwitnessed fall in which he sustained a bloody nose and an x-ray was obtained. Findings include: I. Facility policy and procedure A. The Fall Prevention Program policy, dated 2020, was provided by the nursing home administrator (NHA) on 11/2/21 at 12:50 p.m. It read in pertinent part, When any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, notify the physician and family, and document all assessments and actions. B. The Head Injury policy, dated 2021, was provided by the NHA on 11/3/21 at 10:35 a.m. It read in pertinent part, It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury. Assess residents following a known, suspected, or verbalized head injury. The assessment shall include, at a minimum: vital signs, general condition and appearance, and a neurological evaluation for changes in physical functioning, behavior, cognition, level of consciousness, dizziness, nausea, irritability, and slurred speech/slowness to answer questions. Notify the physician and follow orders for care. Perform neurological checks as indicated or as specified by the physician. Notify family and document all assessments, actions, and notifications. II. Resident #84 A. Resident status Resident #84, age 77, was admitted on [DATE] and readmitted on [DATE]. The resident was discharged from the facility on 9/28/21. According to the September 2021 computerized physician orders (CPO), diagnoses included non-displaced fracture of the greater trochanter of the right femur (added 9/23/21), Alzehimer's disease, anxiety, chronic [CONDITION(S)] with [CONDITION(S)], dependence on supplemental oxygen, muscle weakness, muscle wasting/atrophy, and other signs/symptoms involving cognitive functions and awareness. The 9/9/21 minimum data set (MDS) assessment, revealed the resident was severely cognitively impacted with a brief interview for mental status (BIMS) score of 99. The resident had both short and long term memory problems. The resident had difficulty focusing his attention and was easily distracted or had difficulty keeping track of what was said. This behavior was present and fluctuated. The resident's thinking was disorganized or incoherent. This behavior was present and fluctuated. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting and personal hygiene. B. Record review The care plan for falls related to confusion, incontinence, new admission to facility, unaware of safety needs and wandering was initiated on 9/12/21. Some of the interventions were to anticipate and meet the resident's needs, encourage non-skid footwear of the resident's choice while ambulating or when in wheelchair, maintain a safe environment (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, personal items within reach) and follow the facility fall protocol. The admission data collection fall risk assessment dated [DATE] at 3:14 p.m., revealed a score of five, which indicated at risk. The resident was disoriented times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing and walking. The resident had decreased muscular coordination and had a gait pattern change when walking through a doorway. The resident exhibited jerking motions and was unstable when making turns. The occupational therapy note dated 9/14/21 at 6:47 p.m., revealed the reason for therapy was the resident had impairments in balance, mobility, attention, planning, follow through, problem solving, self-modification, interpersonal interactions, and use of environmental modification strategies resulting in limitations and/or participation restrictions in the areas of interpersonal interactions and relationships, mobility and self-care which required skilled therapy services to assess and modify environmental barriers, assess safety and independence with activities of daily living, assess the need for adaptations/assistive devices, develop and instruct on compensatory strategies, facilitate dynamic standing balance, increase functional activity tolerance and maximize independence with activities of daily living in order to facilitate ability to live in environment with least amount of supervision and assistance. Due to the documented physical impairments and associated functional deficits, without skilled therapeutic intervention, the patient was at risk for: behavioral outbursts, decreased ability to return to prior level of supervision, falls and decreased participation with functional tasks. A nurse note dated 9/19/21 at 12:29 a.m., by a registered nurse (RN) revealed the resident was agitated and more resistive to care this evening. This nurse tried to administer medications three times without success. On the third attempt the resident smacked the nurse's hand away during the explanation of the medications. An attempt was made to assist the resident to the bathroom and the resident refused to walk or sit in his wheelchair. The resident refused to wear his oxygen cannula and would not allow it to be placed on him. Will continue to try to provide care. C. Fall 9/20/21 A situation, background, assessment and recommendation (SBAR) dated 9/20/21 at 6:08 p.m., by the director of nursing (DON) revealed the resident had an unwitnessed fall at 5:30 p.m., this date. The resident was found on his left side. He had a skin tear to his left elbow and bilateral first knuckles. The resident was unable to lay on his back to fully assess for signs of any fractures or dislocations. The resident reported pain on his left hip with pressure and manipulation. A call was placed to his power of attorney and she wanted the resident sent to the emergency department for a hip x-ray to rule out a fracture or dislocation. The 911 call was made and he was sent out at 6:06 p.m. The neurological assessment record was started on 9/20/21 at 5:30 p.m. The assessment columns for 5:30 p.m. and 5:45 p.m. (every 15 minutes for four checks per facility protocol), contained no assessment documentation. There were no assessments for vital signs, level of consciousness (alert, drowsy, stuporous, comatose), pupil reaction, eye signs, eye motor, eye movement, or verbal ability. The fall risk assessment dated [DATE] at 6:16 p.m. revealed a score of 10 or high risk. The resident was disoriented times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing and walking. The resident had decreased muscular coordination. The resident exhibited jerking motions and was unstable when making turns. The interdisciplinary team (IDT) post fall review dated 9/20/21 at 6:18 p.m., revealed the resident had an unwitnessed fall in his room at 5:30 p.m., this date. The resident had a skin tear to his left elbow and bilateral knuckles. The staff could not assess his left hip. The resident complained of pain in his left hip. He was sent to the emergency department for a hip x-ray (the right hip had an x-ray due to resident complaining of pain in right hip at the hospital, which was negative). After return to the facility and upon completion of isolation protocols; the resident would be moved closer to the nurse's station for better visual observations. A nurse note dated 9/20/21 at 10:20 p.m., by an RN revealed the resident returned to the facility by emergent hospital transport at this time. The resident was calm and cooperative with care. The resident did not complain of any discomfort and there were no non-verbal pain cues noted at this time. The resident had a skin tear to his left hand knuckle with a dressing in place and a skin tear to his right hand knuckle without a dressing. He had a skin tear to his left elbow with a dressing in place. The resident was in bed watching television with the bed in a low position. Discussion with the emergency department nurse occurred at 9:30 p.m., this date. The SBAR follow-up note dated 9/21/21 at 12:57 p.m., by a licensed practical nurse (LPN) revealed the continued on follow up with no deficits observed. The resident denied any pain or discomfort at this time. The IDT note dated 9/22/21 at 9:21 a.m., by the DON revealed the IDT met to review the resident's fall status. The resident had a fall on 9/20/21. The fall resulted in a skin tear to the left elbow and bilateral knuckles. The resident complained of hip pain and was sent to the emergency department for evaluation. The IDT investigated the fall on 9/20/21 and determined the cause of the unwitnessed fall. The new interventions were to send the resident to the emergency department for his x-rays and move the resident close to the nurse's station for better visual observation (when he came off isolation precautions). The resident's care plan was reviewed and updated. Staff would continue to monitor and make changes to the plan of care as needed. -However, the resident was not moved closer to the nurse's station for better visual observation (see NHA interview below). Subsequently the resident had another fall on 9/23/21 that caused major injury. Due to isolation for COVID-19, the resident was not moved for visual observation and the facility failed to implement measures to increase supervision after his fall on 9/20/21. D. Fall 9/23/21 The fall risk assessment dated [DATE] at 3:46 p.m., revealed a score of 13 or high risk. The resident was disorientated times-three at all times. The resident had one to two falls in the past three months. The resident had a balance problem while standing. The IDT post fall review note dated 9/23/21 at 3:48 p.m., revealed the resident had a fall at 3:30 p.m., this date. The resident had a (un)witnessed fall with a possible head injury. The resident was found on the floor by therapy. The resident was on his right side with his head leaning on an overside table. The resident wore non-skid socks. He complained of pain in the shoulder related to laying in an awkward position. He was able to move all extremities with purpose with no pain while in a chair. Three staff members transferred the resident to a wheelchair for safety. The resident had a skin tear to the right elbow. It was cleaned with a wound cleanser and a bandage was applied. A nurse note dated 9/23/21 at 3:55 p.m., by the minimum data set coordinator (MDSC) revealed the resident was found on the floor in his room by therapy staff. The resident was on his right side and his head on a table. He was wearing non-skid socks and his oxygen was not in place. The resident complained of pain related to the awkward position he was in. He had a skin tear to his right elbow and first aid was provided. The resident said he hit his head and the fall protocol was initiated. The resident moved all extremities with purpose and he had no complaint of pain. The resident was unable to recall what happened due to being a poor historian. The neurological assessment record was started on 9/23/21 at 3:50 p.m. The assessment columns for 4:05 p.m., 4:20 p.m., 4:35 p.m., 5:05 p.m., 5:35 p.m., and 6:05 p.m., contained no assessment documentation. There were no assessments for vital signs, level of consciousness (alert, drowsy, stuporous, comatose), pupil reaction, eye signs, eye motor, eye movement, or verbal ability. The pain evaluation form dated 9/23/21 at 4:00 p.m., revealed no pain in the past five days. The SBAR summary note dated 9/24/21 at 4:05 p.m., by the MDSC noted the resident had no safety awareness. The resident was found on the floor (in his room) by therapy staff. The resident was on his right side with his head on a table. He was wearing non-skid socks. The resident was not wearing oxygen. The resident complained of pain related to the awkward position he was in. He has a skin tear to his right elbow and first aid was provided. The resident said he hit his head and the fall protocol was initiated. The resident was able to move all extremities with purpose with no pain. The resident was unable to recall what happened due to being a poor historian. A nurse note dated 9/24/21 at 10:23 a.m., by an LPN revealed the nurse practitioner was advised the resident appeared visibly in pain upon waking, however due to his cognition, he was unable to express it verbally. Received a new order for Tylenol 1,000 mg orally three times a day. A nurse note dated 9/24/21 at 1:10 p.m., by an LPN revealed the resident's right hand was observed to be swollen and non-pitting. The resident was unable to open the hand completely. The nurse practitioner was advised and a new order was received to obtain an x-ray of his right hand. The SBAR follow up note dated 9/24/21 at 1:14 p.m., revealed the resident continued on follow up and no deficits were observed. The x-ray was ordered for right hand pain. Pain medications were administered as ordered. Will continue to monitor. A nurse note dated 9/24/21 at 5:03 p.m., by a licensed practical nurse (LPN) revealed the x-ray to the right hand was performed and awaiting results. A nurse note dated 9/24/21 at 5:34 p.m., by an LPN revealed when the resident was assisted back to bed, he was unable to stand on his own. The resident was observed to wince with movement of the right hip. The resident was placed carefully in bed with a pillow between his knees. The nurse practitioner was called and a new order for a STAT (immediate) anterior view x-ray of the resident's right hip. The radiology report dated 9/24/21 at 8:20 p.m., revealed a right hip greater trochanter fracture that was non-displaced. A nurse note dated 9/24/21 at 10:50 p.m., by an RN revealed the results of the right hip x-ray returned with a closed fracture to the right greater trochanter. The hospital was contacted and an order received to send out to the emergency department for further evaluation. The resident was sent by non-emergent transport and left the facility at 10:45 p.m. The SBAR communication note dated 9/24/21 at 10:58 p.m., revealed the x-ray results of the right hip showed a non-dislocated fracture of the right greater trochanter from a fall on 9/24/21. The condition was made worse by movement, physical activities and repositioning. The condition was made better by lying still. The resident had a history of dementia, falls, and metabolic [CONDITION(S)]. The SBAR summary note dated 9/24/21 at 10:58 p.m., revealed the resident had pneumonia, weakness and dementia. He had a history of falls at home combined with new comorbidities. The resident was at a higher risk for falls and fractures. Contact was made with a nurse practitioner who requested the resident be sent to the emergency department for evaluation. The emergency department discharge summary dated 9/25/21 at 4:45 p.m., revealed the resident had intractable pain, acute closed non-displaced fracture of the greater trochanter of the right femur and acute non-displaced fracture of the proximal right olecranon (elbow)with possible intra-articular extension. The admission note dated 9/26/21 at 2:41 p.m., by an LPN revealed the resident returned from the hospital to the facility by non-emergent transport at 12:15 p.m., this date. The resident was in visible pain and pain medications were administered. The resident was admitted with a right femur fracture and a right olecranon fracture. The resident had a cast on the right arm. The resident was confused at baseline and was unable to answer questions properly. The admission data collection for pain dated 9/26/21 at 1:46 p.m., revealed a level of 10 out of ten. The location was in the bone and joint of the right hip and right elbow. Repositioning and walking in the morning makes it worse. Rest reduces the pain. E. Staff interviews The NHA was interviewed on 11/1/21 at 11:10 a.m., and at 11:52 a.m. She acknowledged the times for the six missing neurological assessments for the fall with an injury on 9/23/21. She reviewed the neurological assessment form and agreed the frequency the staff should follow for an unwitnessed fall or a witnessed fall with a head injury was located in the upper right hand corner of the form. The frequency was every 15 minutes ' times four, every 30 minutes ' times four, every hour times four, every 4 hours ' times two and every 8 hours ' times two. She said the staff should complete the neurological assessments accurately and according to this frequency. She said neurological assessments should be completed to make sure there were no negative outcomes from a fall. She said some possible concerns from not completing the assessments might be a head injury, brain bleed, stroke or paralysis. Registered nurse #1 was interviewed on 11/1/21 at 11:20 a.m. She acknowledged the neurological assessment form for the fall on 9/23/21 had six missing neurological assessments. She said for an unwitnessed fall and for a suspected head injury the staff should follow the frequency of neurological assessments located in the upper right hand corner of the neurological assessment record. She said neurological assessments were performed to look for any changes in the resident's cognition or any deviation from the resident's established baseline (a starting point for comparison). She said not completing the neurological assessments might delay any treatments for a head injury or brain bleed. She said some possible concerns from not completing the assessments might be the possibility of missing any additional aberrant neurological findings. Unit manager #2 was interviewed on 11/1/21 at 11:39 a.m. She acknowledged the neurological assessment form for the fall on 9/23/21 had six missing neurological assessments. She said for an unwitnessed fall and for a suspected head injury the staff should follow the frequency of neurological assessments located in the upper right hand corner of the neurological assessment record. She said neurological assessments were performed to check for any changes from the resident's baseline assessments and to check the resident's mentality/cognition for any deviations from the resident's normal. She said some possible concerns from not completing the assessments might be neurological deficits, stroke or paralysis. She said the resident did sustain a fractured hip from the fall. The NHA and the DON were interviewed on 11/2/21 at 4:10 p.m. The NHA acknowledged the two missing neurological assessments for the fall on 9/20/21 and the six missing neurological assessments for the fall with an injury on 9/23/21. The NHA said the neurological assessments should be completed according to the frequency in the upper right hand corner of the neurological assessment record. The NHA said the resident did not sustain any fractures for the fall on 9/20/21. She said the resident went to the emergency department after this fall for an evaluation. She said when he returned to the facility, he had to return to a COVID-19 room on the isolation unit due to his evaluation at the hospital. The NHA said after the second fall on 9/23/21 the resident initially did not have any signs or symptoms of a hip fracture. The NHA said the resident was sent to the emergency department for evaluation and he did have a hip fracture. The NHA said was noted to be a fall risk and was found both times by staff in his room after the falls. She said the resident was confused, exit seeking, restless, had hallucinations, looked for his truck outside the facility and took his oxygen off. She said the resident did receive therapy services at the facility. She said one of the suggested interventions was to move the resident closer to the nurse's station once he came off isolation; however, this intervention was unable to be implemented. The NHA was interviewed on 11/3/21 at 8:32 a.m. She acknowledged the resident had two falls in the facility on 9/20 and 9/23. She said there were no fractures on the first fall, however he did sustain a fracture of the trochanter and olecranon on the second fall. She said the nursing staff did not complete the neurological assessments according to the frequency on the neurological assessment record. The NHA, director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 11/3/21 at 1:00 p.m. The NHA said resident falls were discussed in the 8/24/21 Quality Assurance and Improvement (QAPI) meeting. She said past deficiencies in falls were also discussed. She said nursing staff and medical records staff were educated to ensure the resident medical records were accurate and complete. She said Monday through Friday, resident falls were discussed in the morning meeting and the fall documentation was reviewed. She said they discussed the total number of falls, any injuries, and residents that had multiple falls. III. Resident #33 A. Resident status Resident #33, age 89, was admitted on [DATE]. According to the November 2021 computerized physician orders (CPO), diagnoses included repeated falls, muscle weakness, muscle wasting and atrophy, vascular parkinsonism, and unspecified dementia without behavioral disturbance. The 8/26/21 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of three out of 15. He required one-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. He had had two or more falls with no injury since the prior MDS assessment, and he had had two or more falls with injury since the prior MDS assessment. B. Record review The 9/24/21 Fall Risk Assessment documented Resident #33 was at high risk for falls. Review of the comprehensive care plan, initiated 7/16/19 and last revised 10/19/21, revealed Resident #33 was at risk for falls related to dementia without behavioral disturbances, muscle wasting/weakness and a history of repeated falls. Pertinent interventions included performing activities one to one with the resident in his room, helping the resident with putting on shoes, socks or non-skid socks, and keeping his wheelchair at the bedside when he was asleep for safety, educating staff to anticipate his needs, encouraging the resident to stay in commons areas for visual observation, utilizing a fall mat at bedside, installing non-skid strips on the floor next to his bed, and consulting with neurology and pharmacy for medication reviews and changes. The Post Fall Review assessment dated [DATE] documented Resident #33 had an unwitnessed fall in his room at 10:45 p.m. and first aid was provided to the resident. The fall assessment further documented Resident found on the floor, opposite the fall mat, on his hands and knees with blood coming from both nares. It appeared that he fell while standing on the fall mat and possibly struck his nose on the floor. There was no redness to his face or forehead and no swelling except to the bridge of his nose. Review of Resident #33's electronic medical record (EMR) revealed the following progress notes: 6/16/21 at 11:24 p.m: Appears that resident fell to ground and hit the floor with his face. He continues to be restless at bedtime (HS) and night (NOC) shift.When found, his nose was actively bleeding and there was swelling to the bridge of his nose. Resident confirms that his nose hurts and not his forehead or any other areas. 6/16/21 at 11:31 p.m: Resident found on his hands and knees by the side of his bed with bloody nose. Resident confirms that he fell and his nose hurts. Nurse practitioner (NP) contacted, order received to obtain an immediate (STAT) three view x-ray of facial bones. Will continue to monitor. 6/16/21 at 11:33 p.m: STAT three view x-ray of facial bones ordered at this time related to fall. 6/18/21 at 12:51 p.m: Notified NP about facial x-rays. No abnormal findings. No orders at this time. The facial bone x-ray report for Resident #33 dated 6/17/21 documented the following: Findings: No fracture. The osseous (bone) structures appear intact. The sinuses are clear. Soft tissues appear unremarkable. Old fracture. Conclusion: Normal facial series. Radiographs are insensitive for subtle abnormalities. If clinical concern or symptoms continue to exist, further workup with computed tomography (CT) should be considered. Review of the facility's Neurological Record documentation form revealed neurological checks were to be performed and documented following a resident fall. A resident was to be assessed with each neurological check for: vital signs (including blood pressure, pulse, respirations, and temperature), level of consciousness, pupil size and reaction, eye opening response, motor reflex response of all extremities, and verbal speech response. Per the facility's Neurological Record form, neurological checks were to be completed utilizing the following frequency: -Every 15 minutes times four checks; -Every 30 minutes times four checks; -Every hour times four checks; -Every four hours times two checks; and, -Every eight hours times two checks. Review of Resident #33's Neurological Record form which was initiated on 6/16/21 at 10:45 p.m. revealed the following: -10:45 p.m: all sections on the form were completed; -11:00 p.m: all sections on the form were completed; -11:15 p.m: all sections on the form were completed; -11:30 p.m: all sections on the form were completed; -12:00 a.m: all sections on the form were completed; -12:30 a.m: vital signs section was completed, all other assessment sections were left blank; -1:00 a.m: vital signs section was completed, all other assessment sections were left blank; -1:30 a.m: vital signs section was completed, all other assessment sections were left blank; -2:30 a.m: vital signs section was completed, all other assessment sections were left blank; -3:30 a.m: vital signs section was completed, all other assessment sections were left blank; -4:30 a.m: vital signs section was completed, all other assessment sections were left blank; -5:30 a.m: vital signs section was completed, all other assessment sections were left blank; and -9:30 a.m: documentation on the form revealed the resident sustained another fall at 6:15 a.m. on 6/17/21 and a new Neurological Record form was initiated at that time. Review of the Neurological Record form dated 6/17/21 revealed that all neurological checks had been completed for Resident #33's fall which occurred at 6:15 a.m. C. Unit manager (UM) #2 interview UM #2 was interviewed on 11/3/21 at 9:10 a.m. UM #2 confirmed that the neurological check form for Resident #33's fall on 6/16/21 had not been completed. She said the neurological checks between 12:30 a.m. and 9:30 a.m. did not include the assessment documentation for the resident's level of consciousness, pupil size and reaction, eye opening response, motor reflex response of all extremities, and verbal speech response. UM #2 said neurological checks were to be performed for every unwitnessed fall, or a fall in which the resident was known to have hit their head. She said neurological checks were to be performed per the facility's frequency protocol (see frequency above) and all assessment areas were to be documented thoroughly on the form. UM #2 said it was important to assess residents frequently following a fall in order to ensure that the resident had not sustained a head injury. She said the facility was working on a better process to ensure that staff thoroughly assessed and documented neurological checks after resident falls. IV. Additional interviews Licensed practical nurse (LPN) #4 was interviewed on 11/2/21 at 1:48 p.m. LPN #4 said neurological checks were to be performed for every resident after an unwitnessed fall. She said neurological checks would also be completed if the resident was known to have hit their head. She said nurses were to document the complete assessment on the Neurological Record form, per the facility frequency protocol. The NHA, director of nursing (DON), unit manager (UM) #1, UM #2, regional vice-president of operations (RVPO), and the regional nurse consultant (RNO) were interviewed together on 11/2/21 at 4:30 p.m. The NHA said neurological checks should be completed for the entire monitoring period following a resident fall according to the facility's frequency protocol. She said all sections of the Neurological Record form should be monitored with every neurological check, and documented on the form accurately and timely. LPN #6 was interviewed on 11/3/21 at 8:51 a.m. LPN #6 said neurological checks should be performed if a resident fall was unwitnessed or staff witnessed them hitting their head. She said neurological checks should be initiated immediately after the fall. She said nurses were to check vital signs, hand grasps, eye responsiveness, mentation, pupil reaction, and speech. LPN #6 said the neurological checks should be completed entirely for each assessment and documented for the entire period of the neurological check frequency protocol. Registered nurse (RN) #2 was interviewed on 11/3/21 at 9:20 a.m. RN #2 said neurological checks were initiated immediately after a fall for all unwitnessed falls or a fall in which the resident was witnessed hitting their head. He said the neurological check frequency was listed on the Neurological Record form. RN #2 said nurses should complete a full neurological assessment following the frequency protocol and document all findings on the neurological check form each time. LPN #5 was interviewed on 11/3/21 at 9:43 a.m. LPN #5 said neurological checks included assessing a resident's pupil reaction, hand grasps, vital signs, level of consciousness, and speech. She said neurological checks were to be initiated immediately following an unwitnessed fall or a fall where the resident was known to have hit their head. LPN #5 said it was important to monitor residents for signs of a head injury following an unwitnessed fall. She said neurological checks were performed per the facility's frequency protocol and all information was to be documented in its entirety on the Neurological Record form for each fall.

Based on interviews and record review, the facility failed to ensure the resident ' s environment remained free of accident hazards for one (#15) of one resident reviewed for accident hazards, out of 33 sample residents. Specifically the facility failed to ensure: -Staff followed OT recommendations for the use of a hoyer (mechanical) lift for all transfers and used a sit-to-stand lift for transfers instead; and -Staff addressed Resident #15 ' s reports of pain caused from the use of a sit-to-stand lift during transfers. Findings include: I. Facility policy and procedures The Use of Mechanical Lifting procedure, revised 2/12/19, was provided by the nursing home administrator (NHA) on 1/14/2020 at 11:13 a.m. The procedure read in part: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift .Make sure that all necessary equipment is on hand and in good condition. II. Resident status Resident #15, under [AGE] years old, was admitted on [DATE]. According to the January 2020 computerized physician order, [DIAGNOSES REDACTED]. The 10/25/19 minimum data set (MDS) documented resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #15 required two person physical assistance with transfers, bed mobility, personal hygiene, dressing and toilet use. She had no history of falls in the past six months. (Resident #15's clinical record documented a history of a finger fracture during a hoyer lift transfer in February 2019.) The resident did not reject evaluation or care. III. Record review The transfer care plan initiated on 7/20/18 with a revision date of 1/10/2020 documented in pertinent part . Assistive device for transfers needed: hoyer lift with extensive to dependent assistance of two staff members. The care plan did not document a refusal to use hoyer lift. Resident #15's transfer evaluation completed by the and dated 8/8/19 documented in pertinent part . Resident #15 belongs to category three with a score of 9-14 which means caregiver performs 50 percent (%) of the task or greater. The recommended equipment for residents under this category was total body lift (hoyer) or stand assist as appropriate. The SBAR assessment completed for Resident #15 and documented by licensed practical nurse (LPN(#2)) on 1/10/2020 at 1:02 p.m. reported Resident #15 was experiencing pain to the right (R) shoulder area, complaining of (C/O) pain primarily with standing lift transfers to/from bed, wheelchair and commode. The assessment further reported a R shoulder x-ray result was received and was positive for mild midline clavicular fracture (FX). The electronic medical record showed there was no follow-up with the resident immediately following this assessment. The nursing home administrator (NHA) provided a paper copy of a nursing note dated 1/10/2020 reported by registered nurse (RN(#3)). The document revealed the RN spoke with Resident #15 about the cause of the right clavicle fracture and Resident #15 reported that she believed it occurred two weeks ago during a sit-to-stand transfer using a sit-to-stand lift and sling. The note further documented Resident #15 reported to the nurse that she believed her arm got caught in the sling and it caused a fracture. At this time the resident had not been assessed to be appropriate and safe to use the sit-to-stand lift. The NHA provided an investigation conducted by the facility following the discovery of Resident #15's fractured right clavicle. The investigative report documented several CNAs were interviewed and they all stated Resident #15 frequently refused to be transferred with the hoyer lift. Specifically, the interviews documented CNAs report that Resident #15 complained of pain with the use of the hoyer. A review of the medical record did not document any communication between the CNAs and nurses related to pain. IV. Resident Interview Resident #15 was interviewed on 1/14/2020. The resident stated she sustained a fracture to her right clavicle due to nursing staff unsafely transferring her. She said she had complained of experiencing pain to nursing staff (CNAs and nurses) several times and nothing was done to address her expressed concern during transfers. She added that she was forced to decline to use the hoyer and instead settle for the sit-to-stand as it does not give her the type of pain she experienced with the hoyer lift. Resident #15 also reported she was not provided any education as to why she was not safe to use the sit to stand. She stated what choice did they leave me with when they refused to address my complaint of pain with the hoyer. V. Staff interviews CNA #2 was interviewed on 1/14/2020 at 2:37 p.m. and stated she had been working with Resident #15 for approximately two years. She said the services she performed with Resident #15 included assistance with toileting, general grooming (dressing, hair styling, nail trimming) and other activities of daily living (ADLs). CNA #2 stated she checked the kardex and sometimes asked the nurse how a resident was to be transferred. CNA#2 verified that Resident #15 was transferred with the hoyer since admission, CNA #2 also clarified that Resident #15 was always complaining of pain in her right hand which resulted to Resident #15 ultimately declining to be transferred in the hoyer lift and subsequently preferred the sit-to-stand. Specifically, CNA #2 stated Resident #15 does complain of excruciating pain when transferred in the hoyer sling, she said the resident frequently complained of the sling squeezing her right affected hand resulting in unbearable pain. She concluded the interview stating that she had never performed an unsafe transfer with the resident. However, the resident was to use the hoyer lift not the sit-to-stand lift as was being done by staff. CNA #5 was interviewed on 1/14/2020 at 2:59 p.m. CNA #5 stated she worked relatively well with Resident #15. CNA #5 mentioned the services she performed with Resident #15 which included assistance with toileting, assistance with grooming (dressing, hair styling, nail trimming) and other activities of daily living (ADLs). CNA #5 stated she would know how a resident was to be transferred by asking the resident or the nurse. CNA#5 said Resident #15 was transferred with sit-to-stand as it was the resident preference. CNA #5 added that the resident was recently switched to a hoyer lift. Licensed practical nurse (LPN) #1) was interviewed on 1/15/2020 at 11:57 a.m. LPN#1 reviewed Resident #15's medical record and revealed that the resident was evaluated to be transferred utilizing the hoyer. LPN #1 added that nurses are able to make a judgement on how to safely transfer a resident, however, she clarified that it was best practice to have therapy re-evaluate the resident for the sit-to-stand prior to the facility adopting it as a means to transfer the resident continuously. She verified there was no documentation in the resident's medical record which reported a consultation/request was sent to therapy to assess the resident's safety with sit-to-stand transfer or that the resident was educated on the safety issue that was attributable to her preference of the sit-to-stand lift due to her pain. The rehabilitation program manager (RPM) was interviewed on 1/16/2020 at 12:03 p.m. The RPM clarified that part of the assessment that qualified an individual for a sit-to-stand was a fully functional left and right hand. She stated it was important for an individual to be able to hold on to the sling as a means necessary to brace themself up to be considered safe to use the sit-to -stand. The RPM verified it was unsafe for Resident #15 to use a sit-to-stand given that she had diminished/lost function in the right side of her body. The RPM stated therapy evaluation was necessary to accommodate Resident #15's right hand in the event she complained of pain with hoyer lift. Moreover, the RPM verified that her department did not get a referral from nursing staff to follow-up with Resident #15's complaint of pain while being transferred with the hoyer lift. She concluded the interview by stating that Resident #15 has not been seen or on a therapy caseload in months. VI. Follow-up The 1/14/2020 OT assessment of the resident documented the musculoskeletal system assessment of Resident #15 and reported in pertinent part: -right upper extremity (RUE) range of motion (ROM) was impaired; -right shoulder was impaired, right elbow/ forearm was impaired, right wrist was impaired, right hand impaired; -RUE strength was impaired. The nursing home administrator provided documentation from a follow-up orthopedic appointment which Resident #15 attended on 1/17/2020. The diagnostic result from the appointment reads in pertinent part .Right clavicle film obtained, Resident #15 has an old malunited clavicle fracture. High riding humeral head. No acute fracture .

Based on observations, record review and interview, the facility failed to ensure that the resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#1) of three residents reviewed for quality of care of eight sample residents. Specifically, the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely intervention and hospitalization for Resident #1, which resulted in the resident experiencing an increase in pain level. Cross-reference to: -F689 Accident Hazards, because the facility failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize his risks and keep him safe from injury. -F697 Pain Management, because the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely pain management for Resident #1, which resulted in the resident experiencing an increase in pain level for more than 20 hours before intervention and treatment. Findings include: I.Failure to identify [MEDICAL CONDITION] and timely transport resident to the emergency department for evaluation. A.Resident #1's status Resident #1, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/8/19 minimum data set (MDS) assessment revealed resident had severe cognitive impairment with a brief interview for mental status (BIMS) score one out of 15. The resident required extensive two + staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He was always continent of bowel and had indwelling urinary catheter in place. The pain section on admission revealed, the resident had no scheduled pain medications, he received only as needed pain medication. His pain assessment was completed, pain was identified as occasional, and it was hard to sleep at night due to the pain in the last five days, and day-to-day activities were limited due to the pain. Ongoing pain was rated at the level 5 out of 10. 1.Resident status on admission The baseline care plan created on admission identified that resident was at risk for pain. The list of interventions for pain was generated by software and not specific to the resident. Interventions included evaluate the effectiveness of pain interventions, (no frequency of specific intervention were listed), review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. The resident's preferred way to control pain was not listed but was left blank. 2.Family interview The resident's daughter was interviewed on 8/19/19 at 10:30 a.m. She said the nursing staff contacted her mother, who was a medical power of attorney (MDPOA), about multiple falls that her dad had in the facility in the last ten days. She said the meeting she attended on the 7/15/19 was not a scheduled conference meeting but a requested meeting by her to address all the falls that her dad had so far in the facility. She said after the meeting was over, around 10 a.m. in the morning, she went to her dad's room to give him a kiss: When I approached him, he was sitting in a wheelchair and he was in so much pain, he could only whisper .He was delusional from pain he was whispering help please, help please. His eyes were half closed and his head was moving back and forth. She said she was aware that he had a fall a day before on 7/14/19, but she did not know that he got hurt. She said she was devastated and did not understand why the facility had not sent him to the hospital for an evaluation, instead kept him in bed when he was in so much pain. She said it was more than 20 hours since the fall, and the x-ray of the hip was not done yet, as they were still waiting for the technician to arrive. She said she demanded her dad will be transferred to the hospital. 3.Record review The care plan for pain was initiated on 7/3/19 with no revision date and revealed that the resident was at risk for pain due to [MEDICAL CONDITION]. Interventions included to evaluate the effectiveness of pain interventions (frequency was left blank), review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. To notify physician if interventions are unsuccessful or if current complaint was significant from resident's past experience of pain. The resident preferred pain control method was left blank and contained the following specify medication, treatment. All interventions in comprehensive care plan were the same as in baseline care plan that was created on admission. According to the SBAR note, resident sustained [REDACTED]. Staff busy in other rooms and resident wheels self to (his) room and is found on (the) floor of his bathroom. Resident appears to self-transfer. States he was putting himself in bed. Resident found laying on left side with arm up above head. Skin tear to left elbow. Resident has fallen frequently so has several bruises so difficult to tell if any new but does not appear to be. Resident states back and left hip hurts. The nurse left a note that she was calling physician on call to request an x-ray and had a hard time reaching him/her as no one answered the phone. The interdisciplinary post fall review dated 7/14/19 recommended to request an x-ray from the physician and neurology consultation. The fall report was provided by NHA, dated 7/13/19 and revised on 8/19/19 (the day of the survey). It was unclear what information was edited after the actual incident on 7/13/19. In pertinent part read: found laying on the floor of his bathroom in (his) room. Resident attempted to self transfer to toilet and fell on (the) left side. Three staff assisted up to wheelchair and then to bed. Resident complained of lower back pain and left hip pain. Left hip was slightly swollen and no bruising noted. No abnormalities of left leg/hip. According to the nurses notes dated 7/14/19, resident was placed to bed, and the x-ray of the hip was not done until the next day. -at 5:29 p.m., Res(ident) resting in bed comfortably. (Vital signs within normal limits). Res(ident) is not grimacing or moaning. Bilateral eyes closed with respirations even and unlabored. Awakens to tactile touch and/or verbal stimulation. Res(ident) reports feel better after pain medication was administered. -at 10:10 p.m. note Res(ident) resting in bed. Staff has been checking on Res(ident) every 15 minutes or sooner to ensure that he is aligned properly in the bed and to assess pain. Res is currently resting in bed with bilateral eyes closed. Respirations even unlabored. No acute distress. Left hip continues to appear slight(y) swollen with no increase this evening. No non verbal sign of pain. Bed is in (the) lowest position with Head elevated 15 degrees and mat on (the) floor by Resident. All staff in building. Unit staff were aware that Res(ident) is to remain in bed until further notice. According to the medical administration record (MAR) for (MONTH) 2019, resident had an order to receive [MEDICATION NAME] tablet every six hours as needed for pain. Resident did not receive any pain medications on 7/14/19. According to the nurses' note on 7/15/19 at 10:30 a.m., patient sent out by emergency transport. That was 21 hours after he sustained a [MEDICAL CONDITION] after a fall. The SBAR report completed on 7/15/19 at 1:40 p.m. revealed that resident experienced increased pain and changes in level of consciousness. The facility's failure to timely identify resident's injury after the fall on 7/14/19 contributed to the delay of care and pain. 5. Hospital record review According to history and physical in the emergency department, resident was admitted on [DATE] at 2:10 p.m., resident was presented for evaluation of multiple falls along with new left hip deformity. Resident has had several unwitnessed mechanical falls. Apparently, it happened last night. Staff now noticed a shortening and external rotation at the left hip. Same notes indicated that resident had comminuted (a break of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) and impacted (when the broken ends of the bone are jammed together by the force of the injury) left femur fracture. Resident was admitted to the hospital for the repair of left [MEDICAL CONDITION]. 6. Staff interviews RN #1 who worked in the morning of 7/15/19 was not available for an interview. Assistant director of nursing (aDON) was interviewed on 8/20/19 at 10:30 a.m. He said he was in orientation with RN #1 in the morning on 7/15/19. He said it was his very first day of work in the facility and he was oriented to the cart with RN #1. He said he was following RN #1, when she (RN#1) was passing medications to the resident in the morning. He said he did not know the residents very well and he was not able to tell what his baseline behavior was at that time. He did not know what medications were given to the resident as RN #1 was given medication. Later that day, around 10:30 a.m., he was called to the room to assist with transfer. He said resident was transferred to bed by lift and family was in the room at that time. He said the resident appeared very uncomfortable, he was moaning and guarding his left side at the time of transfer. He said the resident was not able to communicate verbally or number his pain level at that time. He said when the resident was positioned in his bed, he noticed the deformity of the hip and communicated that to RN #1 and the previous aDON who was no longer working in the facility. He said the decision was made to send resident to the emergency room for evaluation. He said x-ray technician came to the facility at the same time as resident was getting ready to be transported to the hospital. Because resident was in a lot of pain and discomfort, the x-rays were completed partially and were stopped because of severe pain the resident experienced. He said the resident's family was in the room all the time and the daughter was very distraught and was crying uncontrollably. The director of nursing (DON) was interviewed on 8/20/19 at 12:13 p.m. She said she was on vacation at the time of the incident. She could not comment on any circumstances regarding the incident. She said she reviewed it after and was aware that RN #1 was reeducated regarding proper pain assessment and assessment of the resident's condition after the fall. Adult protective services representative was contacted on 7/22/19 at 9:45 a.m. She said she received a call from the emergency department (ED) on 7/15/19 regarding the resident who was admitted to the hospital for left [MEDICAL CONDITION] repair. She said staff in the ED were concerned with the delay of care that resident experienced. NHA was interviewed on 8/19/19 at 12:15 a.m. She said she received a call from the ED on 7/15/19 and was informed by caller that incident regarding resident's condition was reported to the adult protective services for further investigation. She said after that she conducted an internal investigation in the facility for negligence and reported allegations to the state facility. She said allegations of negligence were unsubstantiated as resident was not in pain after the fall and nurses completed all post fall assessments timely.

Based on record review and interviews, the facility failed to ensure three (#1, #3 and #2) of four residents reviewed for accidents out of eight sample residents remained as free from accident hazards as possible. Specifically, the facility failed to: -Prevent Resident #1 from sustaining three falls in the facility within eleven days of his admission. The facility identified the resident's numerous fall risks (recent [MEDICAL CONDITION] with surgery, severe cognitive impairment, history of falls, occasional incontinence) but failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize his risks and keep him safe from injury. The resident's third fall in the bathroom on 7/14/19 resulted in second (left) [MEDICAL CONDITION]. The facility staff failed to identify signs and symptoms of broken hip and resident was not hospitalized for [REDACTED]. -Implement resident-centered fall prevention interventions and determine root-cause analysis to prevent multiple falls for Residents #2 and #3. Cross-reference to: -F684 Quality of Care, because the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely intervention and hospitalization for Resident #1, which resulted in the resident experiencing an increase in pain level. -F697 Pain Management, because the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely pain management for Resident #1, which resulted in the resident experiencing an increase in pain level for more than 20 hours before intervention and treatment. Findings include: I. Facility policies and procedures The Fall Management policy revised in (MONTH) (YEAR) was provided on 8/19/19 at 2:10 p.m. by the nursing home administrator (NHA). The policy revealed newly admitted residents will be considered at risk for falls until they are reviewed by the interdisciplinary team (IDT) . When a fall occurs, the resident is assessed for injury be the nurse . The IDT designee will discuss recommended significant changes to the Care Plan to minimize repeat falls with the resident and/or resident ' s representative. The care plan will be reviewed and/or revised as indicated. Care Kardex are updated as appropriate. A. Resident #1's status Resident #1, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/8/19 minimum data set (MDS) assessment revealed resident had severe cognitive impairment with a brief interview for mental status (BIMS) score one out of 15. The resident required extensive two + staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He was always continent of bowel and had indwelling urinary catheter in place. The fall section on admission was not completed. The pain section on admission revealed, the resident had no scheduled pain medications, he received only as needed pain medication. His pain assessment was completed, pain was identified as occasional, and it was hard to sleep at night due to the pain in the last five days, and day-to-day activities were limited due to the pain. Ongoing pain was rated at the level five out of ten. 1. Resident status on admission - at risk for falls The baseline care plan created on admission identified that resident was a high risk for falls. The list of interventions for fall precautions was generated by software and not specific to the resident. Interventions included anticipate and meet the resident ' s needs, make sure the resident ' s call light is within reach and encourage resident to use it, ensure resident is wearing appropriate footwear, and keep his environment safe (the bed in low position, clutter free environment). The initial fall risk assessment completed on 7/2/19 identified resident at low risk for falls which was contrary to the baseline care plan. It did not include all the fall risks that resident had. a. Family interview The resident's daughter was interviewed on 9/19/19 at 10:30 a.m. She said when her father was admitted to the facility (7/2/19), it was communicated to staff members that he was at risk for falls and had a recent fall that resulted in right [MEDICAL CONDITION]. She said nursing staff contacted her mother, who was a medical power of attorney (MDPOA), about multiple falls that her dad had in the facility in the last ten days. She said the meeting she attended on the 7/15/19 was not a scheduled conference meeting but a requested meeting by her to address all the falls that her dad had so far in the facility. She said after the meeting was over, around 10 a.m. in the morning, she went to her dad ' s room to give him a kiss: When I approached him, he was sitting in a wheelchair and he was in so much pain, he could only whisper .He was delusional from pain he was whispering help please, help please. His eyes were half closed and head was moving back and forth. She said she was aware that he had a fall a day before on 7/14/19, but she did not know that he got hurt. She said she was devastated and did not understand why the facility had not sent him to the hospital for an evaluation, instead kept him in bed when he was in so much pain. She said it was more than 20 hours since the fall, and the x-ray of the hip was not done yet, as they were still waiting for the technician to arrive. She said she demanded her dad will be transferred to the hospital. b. Facility record review revealed the facility knew Resident #1 was at high risk for falls, identifying multiple fall risks on admission. Resident sustaining several falls in the facility, the last one resulted in a [MEDICAL CONDITION] that went unnoticed by nursing staff and resident was not hospitalized for [REDACTED]. c. Facility response to identified risks on admission The care plan (CP) initiated on 7/3/19 with no revision date identified resident was at high risk for falls related to weakness and [MEDICAL CONDITION]. Interventions included to start toileting program on 7/8/19, anticipate and meet the resident's needs, be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed, ensure the resident was wearing appropriate footwear, and the environment was safe and free of clutter. The care plan was not filled in but had blanks where it was required to specify the footwear and specifics of safe environment. The facility failed to update resident's care plan after resident sustained [REDACTED]. At that time interdisciplinary team (IDT) review identified that resident was unable to use the call light for assistance and that he should be started on toileting program. The CP for pain was initiated on 7/3/19 with no revision date and revealed that the resident was at risk for pain due to [MEDICAL CONDITION]. Interventions included to evaluate the effectiveness of pain interventions (frequency was left blank), review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. To notify physician if interventions are unsuccessful or if current complaint is a significant from resident ' s past experience of pain. The resident preferred pain control method was left blank and contained the following specify medication, treatment. The Kardex, with no initiation and revision date revealed that for safety resident was encouraged to use call light to call for assistance, and he was able to transfer with the assistance of two staff members. Interventions did not include any specifics about resident's routine preference, behavior, or toileting program that resident was supposed to be started on. According to primary care provider note dated 7/3/19, resident had unspecified dementia without behavioral disturbance: continue safety measures: bed in low position and locked, floor mat at bedside, frequent monitoring by staff, continue supportive care. Continue fall prevention measures, monitor. Physician's recommendations were not documented in the care plan or Kardex. There was no evidence that facility implemented frequent checks for resident on admission. According to the nurses note dated 7/5/19 Resident impulsive, does not call for help tries to get out of bed. Requires redirection. Unable to recall events. Looks for his spouse wanting to get help her. Facility was aware of resident's behavior, but did not initiate any special precautions for impulsive behavior. 2. Facility failure to develop and communicate effective interventions based on thorough investigations after falls 7/5, 7/13, and 7/14/19, to minimize the resident's risks and keep him safe from injury. Record review revealed the facility failed to comprehensively evaluate Resident #1's multiple falls in order to care plan effective, resident-specific interventions to address his known fall risks and to keep him safe from additional falls and injury. a. Fall #1 on 7/5/19 (3 days after admission) According to the (Situation, background, assessment, recommendation) SBAR note, resident sustained [REDACTED]. He was sitting on the floor mat next to his bed with head on the pillow. Legs on the floor. Toileting marked as predisposing factor. The interdisciplinary post fall review dated 7/5/19 revealed that resident was not able to use call light in the room or bathroom due to cognitive abilities. Resident stated that he was trying to go to the bathroom when he fell . Recommendations included to start resident on toileting program and review his care plan. The fall report was provided by NHA, dated 7/5/19 and revised on 8/19/19 (the day of the survey). It was unclear what information was edited after the actual incident on 7/5/19. Review of the resident's care plan demonstrated his care plan was not updated with new interventions and resident was not started on toileting program. b.Fall #2 on 7/9/19 According to the occupational therapy note dated 7/9/19, resident rolled out of bed on the same date. There were no investigation or nurses notes about this fall. c.Fall #3 on 7/13/19 According to the SBAR note, resident sustained [REDACTED]. Resident was sitting with (his) back to (the) wall and toilet on (the) left. Turned slightly to left side. Resident was unable to tell the nurse what happened. The note below read: staff is frequently checking and toileting him and he stays at nursing station for increased supervision. The interdisciplinary post fall review dated 7/13/19 recommended to update the care plan, call family for care conference and continue working on strengthening with physical and occupational therapy. The review by the team revealed that resident was left at the nurses station alone, he wandered into an unoccupied room and tried to self-transfer in the bathroom. No other interventions were mentioned. There was no follow up regarding toileting program that was recommended after fall #1. Resident ' s care plan was not updated. The fall report was provided by NHA, dated 7/13/19 and revised on 8/19/19 (the day of the survey). It was unclear what information was edited after the actual incident on 7/13/19. The fall report revealed, resident was assessed by a registered nurse (RN) after the fall on 7/13/19. He was found lying on his left side and he reported having a pain in his left side. He had skin tears on his right and left elbows. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (right hip surgery, limited range of motion, severe cognitive impairment) and on a comprehensive review of the 7/5/19, and 7/13/19 falls, contributed to the lack of effective interventions to prevent another fall the next day. d.Fall #4 on 7/14/19 According to the SBAR note, resident sustained [REDACTED]. Staff busy in other rooms and resident wheels self to (his) room and is found on (the) floor of his bathroom. Resident appears to self transfer. States he was putting himself in bed. Resident found laying on left side with arm up above head. Skin tear to left elbow. Resident has fallen frequently so has several bruises so difficult to tell if any new but does not appear to be. Resident states back and left hip hurts. The nurse left a note that she was calling physician on call to request an x-ray and had a hard time reaching him/her as no one answered the phone. The interdisciplinary post fall review dated 7/14/19 recommended to request an x-ray from the physician and neurology consultation. The fall report was provided by NHA, dated 7/13/19 and revised on 8/19/19 (the day of the survey). It was unclear what information was edited after the actual incident on 7/13/19. In pertinent part read: found laying on the floor of his bathroom in (his) room. Resident attempted to self transfer to toilet and fell on (the) left side. Three staff assisted up to wheelchair and then to bed. Resident complained of lower back pain and left hip pain. Left hip slightly swollen no bruising to note. No abnormalities of left leg/hip. According to the nurses notes dated 7/14/19, resident was placed to bed, and the x-ray of the hip was not done until the next day. -at 5:29 p.m., Res(ident) resting in bed comfortably. (Vital signs within normal limits). Res(ident) is not grimacing or moaning. Bilateral eyes closed with respirations even and unlabored. Awakens to tactile touch and/or verbal stimulation. Res(ident) reports feel better after pain medication was administered. -at 10:10 p.m. note Res(ident) resting in bed. Staff has been checking on Res(ident) every 15 minutes or sooner to ensure that he is aligned properly in the bed and to assess pain. Res is currently resting in bed with bilateral eyes closed. Respirations even unlabored. No acute distress. Left hip continues to appear slight(y) swollen with no increase this evening. No non verbal sign of pain. Bed is in (the) lowest position with Head elevated 15 degrees and mat on (the) floor by Resident. All staff in building. Unit staff aware that Res(ident) is to remain in bed until further notice. According to the medical administration record (MAR) for (MONTH) 2019, resident had an order to receive [MEDICATION NAME] tablet every six hours as needed for pain. Resident did not receive any pain medications on 7/14/19. According to the nurses note on 7/15/19 at 10:30 a.m., patient sent out by emergent transport. That was 21 hours after he sustained a [MEDICAL CONDITION] after a fall. The SBAR report completed on 7/15/19 at 1:40 p.m. revealed that resident experienced increased pain and changes in level of consciousness. The facility's failure to develop interventions based on a comprehensive assessment of the resident's specific fall risks (recent [MEDICAL CONDITION] with surgery, severe cognitive impairment, history of falls, occasional incontinence), failure to add planned interventions to the care plan, and failure to comprehensively review the 5/13/19 fall, contributed to the lack of effective interventions to prevent resident experiencing another fall. 5. Hospital record review According to history and physical in the emergency department, resident was admitted on [DATE] at 2:10 p.m., resident was presented for evaluation of multiple falls along with new left hip deformity. Resident has had several unwitnessed mechanical falls. Last fall was apparently last night. Staff now noticed shortening and external rotation at the left hip. Same noted indicated that resident had comminuted (a break of the bone into more than two fragments. Since considerable force and energy is required to fragment bone, fractures of this degree occur after high-impact trauma) and impacted (when the broken ends of the bone are jammed together by the force of the injury) left femur fracture. Resident was admitted to the hospital for the repair of left [MEDICAL CONDITION]. 6. Staff interviews The certified nurses aide (CNA) #1 was interviewed on 8/20/19 at 10:05 a.m. She said she was familiar with the resident, and provided direct care to him when he was in the facility. She said he was in the facility just for a couple of weeks. When he was initially admitted , he was in a lot of pain from hip surgery he could not sleep well sometimes. Resident was a one person transfer, and sometimes two people transfer, when he was more confused. She said 7/15/19 was her first day working after vacation and she had not seen the resident for a few days. When she came to his room in the morning of 7/15/19, he was moaning and making sounds. He appeared to be in a lot of pain. I walked to RN #1 and told her that, she said the resident had a fall last night. I don ' t know if she gave him anything for pain, but I told her that he was in pain. She said assistant director of nursing (ADON) assisted her transferring resident from the bed to the wheelchair in the morning around 6:30 a.m. She said resident stayed in the wheelchair until after the family conference around 10:00 a.m. His daily routine was to be up for breakfast and after meals when other residents required care we usually leave him next to the nurses station where nurses can keep an eye on him. A lot of times he appeared very uncomfortable in his chair, he was always uneasy when he was here. He would usually look for his wife and keep asking where she was. She said the resident did not use the call light for assistance. She said she did not know if the resident was on a toileting program. She said he would frequently say that he needed to go to the bathroom even after being toileted. She said resident had an indwelling foley catheter, but would forget every time that he had it. She said there were no charting or documentation to complete for his toileting, that usually done for someone on toileting program. She said the resident received incontinence care every two hours or when he requested. She said the resident did not have any falls on her shift. She said she was aware that he was high risk for falls and she would check on him when she could, or when she would walk by his room. RN #1 who worked in the morning of 7/15/19 was not available for an interview. Assistant director of nursing (aDON) was interviewed on 8/20/19 at 10:30 a.m. He said he was in orientation with RN #1 in the morning on 7/15/19. He said it was his very first day of work in the facility and he was oriented to the cart with RN #1. He said he was following RN #1 when she was passing medications to the resident in the morning, he did not know the residents very well and he was not able to tell what was his baseline behavior at that time. He did not know what medications were given as RN #1 was given medications. Later that day, around 10:30 a.m. he was called to the room to assist with transfer. She said the resident was transferred to bed by lift and family was in the room at that time. She said resident appeared very uncomfortable, he was moaning and guarding his left side at the time of transfer. She said resident was not able to communicate verbally or number his pain level at that time. He said when the resident was positioned in his bed, he noticed the deformity of the hip and communicated that to RN #1 and previous aDON who was no longer working in the facility. He said the decision was made to send the resident to the emergency room for evaluation. He said the x-ray technician came to the facility at the same time as the resident was getting ready to be transported to the hospital. Because the resident was in a lot of pain and discomfort, the x-rays were completed partially and were stopped because of severe pain the resident experienced. He said the resident ' s family was in the room all the time and daughter was very distraughtand was crying uncontrollably . He said residents that were on toileting program would be initially observed to identify a toileting pattern that would be later used to predict their toileting preferences. He said such intervention should be documented in Kardex and care plan. The occupational therapist (OT) #1, was interviewed on 8/20/19 at 10:55 a.m. She said residents had advanced dementia, he had no safety awareness, he did not understand and did not follow the directions, and was very fearful of movement. The OT #2, was interviewed on 8/20/19 at 11:43a.m. She said she worked with the resident until 7/10/19. She said the resident required two person assistance. She said he could not do a lot as he was in a lot of pain, which was usual for anyone after hip replacement. She said she did not know if the resident received any pain medications prior to therapy, but the understanding with nursing was that that was the plan. When he was in pain he would straighten his leg and he would say it hurts a lot. She said he was not always say that he was in pain and it was his behavior that he would show it with. She said he would not be able to give numeric scale of pain. The director of nursing (DON) was interviewed on 8/20/19 at 12:13 p.m. She said she was on vacation at the time of the incident. She could not comment on any circumstances regarding the incident. She said she reviewed it after and was aware that RN #1 was reeducated regarding proper pain assessment and assessment after the fall. NHA was interviewed on 8/19/19 at 12:15 a.m. She said she received a call from the emergency department on 7/15/19 and was informed by caller that incident regarding resident ' s condition was reported to the adult protective services for further investigation. She said after that she conducted an internal investigation in the facility for negligence and reported allegations to the state facility. She said allegations of negligence were unsubstantiated as resident was not in pain after the fall and nurses completed all post fall assessments timely. On 8/20/19 (after survey exit) facility submitted a timeline for Resident #1. Facility stating that bladder wheel was initiated on 7/11/19. They did not provide any additional information regarding the outcome of the bladder wheel assessment. Facility provided quality assurance and performance improvement documents that they identified on 8/15/19 that sometimes post fall assessments were missing certain components. The action plan was initiated on the same day. III. Resident #3 1. Resident status Resident #3, age 72, was admitted on [DATE]. According to the (MONTH) 2019 CPO, pertinent [DIAGNOSES REDACTED]. The 7/23/19 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 resident required supervision with one person physical assistance for ADLs of bed mobility, transfers, dressing, locomotion and toileting. He was steady at all times during transitions and walking, and had no limitations in his range of motion. The resident used a walker for mobility. He was always continent of bladder and bowel. 2. Record review The fall care plan, initiated 7/23/18, documented the resident was a high fall risk related to decreased mobility. Interventions included: -Anticipate and meet the resident's needs, initiated 7/23/18 -Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance, initiated 7/23/18 -Ensure the resident is wearing appropriate footwear when mobilizing in the wheelchair, initiated 7/23/18 -(Resident) needs a safe environment with: (SPECIFY: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; slide rails as ordered, handrails on walls, personal items within reach), initiated 7/23/18 -6/27/19 PT/OT (physical therapy/occupational therapy) referral after incident, initiated 8/19/19 -7/19/19 PT to evaluate and treat, initiated 7/19/19 -7/22/19 continue to work with PT/OT on strengthening, initiated 8/19/19, and -8/9/19 night lights to be added to room, initiated 8/12/19. The 4/19/19 fall risk assessment revealed the resident was at low risk for falls. The resident's falls over the past six months were reviewed. 6/26/19 Fall The 6/26/19 SBAR form documented the resident had an unwitnessed fall and was found standing in his room with a bloody area to his left forehead. The resident had a laceration above his left eye and a skin tear to his left forearm. The resident was sent out to the ER, evaluated and had no further injuries, and returned to the facility with sutures to his left [MEDICAL CONDITION]. The SBAR documented the NP and the resident's family member had been contacted regarding the fall on 6/26/19 at 3:00 p.m. Neurological checks were provided starting on 6/26/19 at 5:00 p.m. and indicated the resident was at the hospital from 6/26/19 5:30 p.m. until 6/26/19 at 10:30 p.m. There were no nursing progress notes on 6/26/19 or 6/27/19 related to the fall. There was no documentation provided of what time the resident was sent to the ER or that neurological checks were completed between 3:00 p.m. and 5:00 p.m. on 6/26/19. The 6/27/19 interdisciplinary post-fall review documented the resident's unwitnessed fall occurred on 6/27/19 at 3:20 a.m. The interdisciplinary team recommended PT and OT as a fall intervention. The 7/3/19 nursing note documented the IDT had met to review Resident #3's fall on 6/27/19. The note documented the fall resulted in a laceration over the left eye. The note documented IDT investigated the fall on 6/28/19 and determined the cause was, the sentence was not completed. The note documented the interventions for PT and OT were implemented on 6/28/19. Therapy documentation revealed the resident was evaluated for OT on 6/25/19 (prior to 6/26/19 fall) and the resident did not begin PT services until 7/19/19. 7/18/19 Fall The 7/18/19 nurse progress note, incident report and SBAR form revealed Resident #3 fell face down at 2:00 p.m. in the hallway next to the nurse's cart. The resident was observed to have a bloody nose, a skin tear to his left forearm, and small skin tears to his left hand. The resident was sent to the ER at 2:30 p.m. and returned at 7:30 p.m. with a nose fracture. The 7/18/19 interdisciplinary post-fall review documented the unwitnessed fall occurred on 7/18/19 at 2:00 p.m. The note documented that the fall occurred at the nurses station, and it was unknown what the resident was doing at the time of the fall. The note did not include staff interviews such as by the staff members who were present in the hallway when the fall occurred. The post-fall review also did not include a root cause analysis. The IDT recommended fall interventions to be PT/OT to evaluate and treat. Per review of the medical record, the resident had surgery on 7/15/19 for cardiac catheterization and had changes to his cardiovascular medications following the procedure. The 7/16/19 NP note documented the resident's medication regimen included three medications for cardiovascular disease ([MEDICATION NAME], atorvastatin, and imdur) and three medications for hypertension ([MEDICATION NAME] and [MEDICATION NAME]). The NP documented the [MEDICATION NAME] was a new medication started as the resident had high blood pressure on 7/15/19. The NP documented for staff to monitor for side effects of [MEDICATION NAME], such as [MEDICAL CONDITION] and dizziness. - The (MONTH) 2019 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The medication was documented as administered on both days. The resident was receiving OT services (see above) as of 6/25/19. The resident began PT services as of 7/19/19 with the goal to improve balance, activity tolerance, ambulation tolerance, and functional mobility to reduce the risk of falls. The 7/19/19 fall risk assessment revealed the resident was at high risk of falls, with risk factors as intermittent confusion, one to two falls in the past three months, required use of assistive devices, taking one to two high risk medications, and having one to two high risk medical conditions. 7/20/19 Fall The SBAR form on 7/20/19 at 9:41 a.m. documented the resident had a fall with bumps, worsened by bending over, not asking for assistance, not sleeping. The form did not clarify what fall with bumps meant. The form documented the resident had been non-compliant with asking for assistance and would not rest in his room in bed. The form documented the resident fell asleep in a chair in the hallway, and was found by a CNA kneeling by the chair. The form documented the resident had a hematoma to his right elbow and a scratch to his right upper forehead. The form was completed by a licensed practical nurse (LPN) and did not indicate a registered nurse (RN) assessed the resident for injuries immediately after the unwitnessed fall. Neurological checks were provided for 7/20/19, and indicated the resident was out to the hospital on [DATE] at 11:00 a.m. until 2:30 p.m. The nurse progress note on 7/21/19 at 10:26 a.m. documented the resident had declined, with extreme lethargy, was only alert to himself, though his neurological checks were within normal limits. The medical provider was contacted and orders were received to send the resident to the ER for evaluation. The nurse progress note on 7/21/19 at 10:45 a.m. documented the resident was assessed by an RN, after being notified by an LPN that the resident had a change in his level of consciousness. The resident was at baseline, and vital signs and neurological checks were within normal limits. The note documented it was also noted in SBAR that patient had a scratch to his (right) forehead. With assessment a raised hematoma is noted to patient's R (right) forehead. The note further documented the resident had significant fall history, baseline impulsiveness, poor safety awareness and required frequent cueing to maintain his safety. The note documented the resident had his bed placed in a low position while he was in bed and the resident's room was directly in front of the nurse's station for frequent observation to ensure safety. The 7/20/19 incident report and 7/20/19 interdisciplinary post-fall review documented the resident had a fall face down by the nurses station and was found bleeding from the nose (same as the 7/18/19 fall). The incident report and interdisciplinary post-fall review did not discuss the resident's fall with bumps in the hallway at nighttime resulting in the hematoma to his right elbow and scratch to right upper forehead. The IDT recommended PT/OT to continue working with the resident. The 7/22/19 PT note documented the resident scored a 29 out of 56 on the Berg Balance Assessment which indicated that he was a very high fall risk. The facility provided daily 15 minute checks for Resident #3 from 7/23/19 to 7/30/19. The 7/26/19 physician note documented the resident had shuffling gait, mask-like expression and coarse tremors of the upper extremities, and the resident was started on [MEDICATION NAME] (anti-Parkinsonian medication). The 8/1/19 PT note documented the resident scored a

Based on observations, record review and interview, the facility failed to ensure pain management services for one (#1) of three out of eight sample residents. Specifically, the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely pain management for Resident #1, which resulted in the resident experiencing an increase in pain level for more than 20 hours before intervention and treatment. Prior to the fall with left facture at the facility, the facility failed to manage the resident's pain resulting in unrelieved pain and reduced participation with therapy. Cross-reference to: -F689 Accident Hazards, because the facility failed to develop, communicate and implement effective interventions based on thorough investigations after each fall, in order to minimize his risks and keep him safe from injury. -F684 Quality of Care, because the facility failed to identify signs and symptoms of a [MEDICAL CONDITION] after a fall in order to provide timely intervention and hospitalization for Resident #1, which resulted in the resident experiencing an increase in pain level. Findings include: I.Failure to provide sufficient pain control prior to therapy and after the fall with injury. A.Facility policy and procedure The Pain Management policy, revised (MONTH) (YEAR), was provided on 8/19/19 at 2:10 p.m. by the nursing home administrator (NHA). The policy read in part, The pain evaluation will be completed in the following circumstances: resident reports inadequate pain control; or resident is identified with a new onset of pain or displays new signs or symptoms of pain. Each resident with pain management needs will have a pain management plan initiated. The care plan will have individualized interventions related to that resident's individual control of pain. The care plan should include both pharmacological and non-pharmacological pain management interventions. The Care Kardex is updated, if necessary. B.Resident #1's status Resident #1, age 82, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 7/8/19 minimum data set (MDS) assessment revealed resident had severe cognitive impairment with a brief interview for mental status (BIMS) score one out of 15. The resident required extensive two + staff physical assistance for bed mobility, transfers, dressing, toileting and personal hygiene. He was always continent of bowel and had indwelling urinary catheter in place. The pain section on admission revealed, the resident had no scheduled pain medications, he received only as needed pain medication. His pain assessment was completed, pain was identified as occasional, and it was hard to sleep at night due to the pain in the last five days, and day-to-day activities were limited due to the pain. Ongoing pain was rated at the level 5 out of 10. 1.Resident status on admission The baseline care plan created on admission identified that resident was at risk for pain. The list of interventions for pain was generated by software and not specific to the resident. Interventions included evaluate the effectiveness of pain interventions, (no frequency of specific intervention were listed), review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition, notify physician if interventions were unsuccessful or if current complaint was a significant change from residents past experience of pain. The resident's preferred way to control pain was not listed but was left blank. 2.Family interview The resident's daughter was interviewed on 8/19/19 at 10:30 a.m. She said the nursing staff contacted her mother, who was a medical power of attorney (MDPOA), about multiple falls that her dad had in the facility in the last ten days. She said the meeting she attended on the 7/15/19 was not a scheduled conference meeting but a requested meeting by her to address all the falls that her dad had so far in the facility. She said after the meeting was over, around 10 a.m. in the morning, she went to her dad's room to give him a kiss: When I approached him, he was sitting in a wheelchair and he was in so much pain, he could only whisper .He was delusional from pain he was whispering help please, help please. His eyes were half closed and his head was moving back and forth. She said she was aware that he had a fall a day before on 7/14/19, but she did not know that he got hurt. She said she was devastated and did not understand why the facility had not sent him to the hospital for an evaluation, instead kept him in bed when he was in so much pain. She said it was more than 20 hours since the fall, and the x-ray of the hip was not done yet, as they were still waiting for the technician to arrive. She said she demanded her dad will be transferred to the hospital. 3.Record review The care plan for pain was initiated on 7/3/19 with no revision date and revealed that the resident was at risk for pain due to [MEDICAL CONDITION]. Interventions included to evaluate the effectiveness of pain interventions (frequency was left blank), review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. To notify physician if interventions are unsuccessful or if current complaint was significant from resident's past experience of pain. The resident preferred pain control method was left blank and contained the following specify medication, treatment. According to the medication administration record (MAR) for (MONTH) 2019, resident was receiving the following medications for pain: -[MEDICATION NAME] Tablet 5-325 milligram (mg), give 1 tablet by mouth every six hours as needed for pain. -[MEDICATION NAME] Tablet 325 mg, give 650 mg by mouth every four hours as needed for pain. The resident did not have any routinely scheduled medications for pain. The resident was monitored for pain every shift starting 7/3/19. During his stay in the facility he sustained four falls, on 7/5/19, 7/9/19, 7/13/19, and 7/14/19. On average the resident's pain fluctuated from 3-6 out of 10. Resident's pain was not recorded on the MAR on 7/14/19, the day he sustained a fall and fractured his left hip. No pain medications were administered to resident on 7/13/19 (after fall #3) and 7/14/19 (after fall #4 with [MEDICAL CONDITION]). Interdisciplinary notes below demonstrate that the resident experienced significant pain during the therapy, and he was not given all available pain control medications that were available to him. According to physical therapy (PT) notes, resident complained of pain on the following days: -7/8/19 reports my legs hurt referring to right hip, was not able to quantify pain level, and had decreased willingness to weight bear through right lower extremity; -7/9/19 resident reported pain and demonstrated demonstrate decreased willingness to weight bear through right lower extremity It hurts too much; -7/10/19 resident unable to quantify pain but continues to demonstrate decreased willingness to weight bear through right lower extremity; -7/12/19 note read resident has expected pain in left hip -7/15/19 complaint of pain in both hips, he was unable to participate in therapy due to new onset of pain in left lower extremity; According to the MAR, resident did not receive all available pain medications on 7/8/19, 7/9/19, 7/10/19, and 7/12/19. He was not able to participate fully in physical therapy. According to the speech therapy (ST) notes resident experienced pain on the following days: -7/11/19 resident appears he is in pain as he grimaces when he moves his leg. Pan medications changed from (as needed) to scheduled ; (According to the MAR resident did not have scheduled pain medication during his stay). According to occupational therapy (OT) notes resident experienced pain on the following days: -7/9/19 resident refused pain medications (MAR shows resident received only morning pain medication, no refusals documented for midday and afternoon). -7/10/19 pain level was seven out of 10 (MAR shows resident received only morning dose of pain medication) -7/12/19 resident was reporting six out of 10 pain level with movement in bed; (Per MAR only morning dose of pain medication was administered) -7/13/19 pain level was recorded as nine out of 10 on the right hip. The note below read required three attempts before resident was able to participate - stated he hurts too much to be able to get out of the bed, did eventually but required more assistance than previously. Needs increased assistance for all transfers, pain is limiting ability to increase independence. (Per MAR resident received Tylenol for pain level of four, [MEDICATION NAME] was not administered that day). Documented pain levels on the MAR were significantly below documented pain levels by therapy. There was no evidence if resident was pre-medicated for pain prior to the physical or occupational therapy. Therapy notes did not specify the time frame that they worked with the resident. 6. Staff interviews The certified nurses' aide (CNA) #1 was interviewed on 8/20/19 at 10:05 a.m. She said she was familiar with the resident, and provided direct care to him when he was in the facility. She said he was in the facility just for a couple of weeks. When he was initially admitted , he was in a lot of pain from hip surgery and he could not sleep well sometimes. She said the resident was a one person transfer, and sometimes two people transfer, when he was more confused. She said 7/15/19 was her first day working after vacation and she has not seen the resident for a few days. When she came to his room on the morning of 7/15/19, he was moaning and making sounds. He appeared to be in a lot of pain. She said, I walked to RN #1 and told her that, she said the resident had a fall last night. I don't know if she gave him anything for pain, but I told her that he was in pain. She said RN #1 assisted her transferring resident from bed to the wheelchair in the morning around 6:30 a.m. She said the resident stayed in the wheelchair until after the family conference around 10:00 a.m. She said the resident's daily routine was to be up for breakfast and after meals. She said When other residents required care we usually leave him next to the nurses station where nurses' can keep an eye on him. A lot of times he appeared very uncomfortable in his chair, he was always uneasy when he was here. He would usually look for his wife and keep asking where she was. She said the resident did not use the call light for assistance. She said she did not know if the resident was on the toilet. She said he would frequently say that he needed to go to the bathroom even after being toileted. She said the resident had an indwelling catheter, but would forget every time that he had it. She said there was no charting or documentation to complete for his toileting, which was usually done for someone on a toilet program. She said the resident received incontinence care every two hours or when he requested. She said the resident did not have any falls on her shift. She said she was aware that he was high risk for falls and she would check on him when she could, or when she would walk by his room. RN #1 who worked in the morning of 7/15/19 was not available for an interview. Assistant director of nursing (aDON) was interviewed on 8/20/19 at 10:30 a.m. He said he was in orientation with RN #1 in the morning on 7/15/19. He said it was his very first day of work in the facility and he was oriented to the cart with RN #1. He said he was following RN #1, when she (RN#1) was passing medications to the resident in the morning. He said he did not know the residents very well and he was not able to tell what his baseline behavior was at that time. He did not know what medications were given to the resident as RN #1 was given medication. Later that day, around 10:30 a.m., he was called to the room to assist with transfer. He said resident was transferred to bed by lift and family was in the room at that time. He said the resident appeared very uncomfortable, he was moaning and guarding his left side at the time of transfer. He said the resident was not able to communicate verbally or number his pain level at that time. He said when the resident was positioned in his bed, he noticed the deformity of the hip and communicated that to RN #1 and the previous aDON who was no longer working in the facility. He said the decision was made to send resident to the emergency room for evaluation. He said x-ray technician came to the facility at the same time as resident was getting ready to be transported to the hospital. Because resident was in a lot of pain and discomfort, the x-rays were completed partially and were stopped because of severe pain the resident experienced. He said the resident's family was in the room the entire time and the daughter was very distraught and crying uncontrollably. He said residents that were on the toileting program would be initially observed to the toileting pattern that would be later used to predict their toileting preferences. He said such intervention should be documented in the Kardex and care plan. The occupational therapist (OT) #1, was interviewed on 8/20/19 at 10:55 a.m. She said residents had advanced dementia, he had no safety awareness, he did not understand and did not follow the directions, and was very fearful of movement. The OT #2, was interviewed on 8/20/19 at 11:43 a.m. She said she worked with the resident until 7/10/19. She said the resident required two person assistance. She said he could not do a lot as he was in a lot of pain, which was usual for anyone after hip replacement. She said she did not know if resident received any pain medications prior to therapy, but the understanding with nursing was that that was the plan. When he was in pain he would straighten his leg and he would say it hurts a lot. She said he was not always say that he was in pain and it was his behavior that he would show it with. She said he would not be able to give numeric scale of pain due to his cognition. The director of nursing (DON) was interviewed on 8/20/19 at 12:13 p.m. She said she was on vacation at the time of the incident. She could not comment on any circumstances regarding the incident. She said she reviewed it after and was aware that RN #1 was reeducated regarding proper pain assessment and assessment after the fall. NHA was interviewed on 8/19/19 at 12:15 a.m. She said after that she conducted an internal investigation in the facility for negligence and reported allegations to the state facility. She said allegations of negligence were unsubstantiated as resident was not in pain after the fall and nurses completed all post fall assessments timely.

Based on observation, record review and interview, the facility failed to ensure appropriate supervision and interventions to prevent accidents for two (#2 and #3) of ten sample residents. Specifically, the facility failed to adequately communicate and implement texture modifications and provide supervision to resident #2, who was at risk for aspiration. The resident was found unresponsive in her room with food at the back of her throat. Additionally, the facility failed to communicate and implement texture modifications for resident #3, who was also assessed as being at risk for aspiration. The facility's failures created a situation of immediate jeopardy for serious resident harm. The findings included: I. Immediate Jeopardy a. Findings leading to Immediate Jeopardy A review of resident medical records in conjunction with interviews of facility staff demonstrated resident #2 was found unresponsive and not breathing in her room during an unsupervised meal in which she requested and was served a food that fell outside of the texture modifications ordered to prevent aspiration. Nursing staff described removing a large piece of food from the back of the resident's throat during a mouth sweep, and interviews revealed additional interventions to assist the resident to complete a safe swallow were not in place at the time of the incident. The resident passed away. At the time of the investigation, observation, interviews and record review demonstrated the facility had additional residents at risk for aspiration who often ordered and were served meals that fell outside of their ordered textures. While honoring resident preference, the facility failed to assess, care plan, or implement interventions (such as increased supervision, physical cues for safe swallowing techniques, or slight modifications to the preferred food to facilitate swallowing) to mitigate the increased aspiration risk posed by these foods. During a meal observation, resident #3, who was identified as being at increased risk for aspiration and had been ordered to receive a mechanical soft diet, was served a cheeseburger in her room. Staff did not provide recommended approaches to facilitate safe swallowing, and the resident was left unsupervised in her room. b. Imposition of Immediate Jeopardy On [DATE] at 4:05 p.m. the nursing home administrator (NHA), director of nursing (DON), and corporate nurse consultant (CNC) were notified the facility's failure to implement a system to communicate texture modifications and specify needs for supervision created a situation of immediate jeopardy for serious resident harm. c. Facility response and removal of Immediate Jeopardy On [DATE] at 10:28 a.m., the NHA submitted the following plan (draft 7) to remove the immediate jeopardy. The plan read: Please consider the following plan to remove immediate jeopardy for (the facility) related to immediate jeopardy in F323: - Facility will offer resident #3 the recommended food texture. If accepted, resident #3 will receive the level of supervision recommended by the speech therapist. If she requests food outside of the recommended texture, she will be provided food of choice and 1:1 supervision by nursing staff. - Facility will offer recommended diet textures to all other residents identified as at risk for aspiration, and will provide the level of supervision recommended by the speech therapist. If any resident requests an item outside of their recommended texture, they will be provided their food of choice and 1:1 supervision by nursing staff. - Speech therapist completed a review on [DATE] of all residents who prefer to eat foods/drink fluids at a level higher than what is ordered to determine the level of supervision required while they are consuming such food/fluids. The speech therapist will review and revise the care plan for all residents at risk for aspiration on [DATE]. - Facility conducted house-wide audit of all residents to ensure the proper diet is indicated in the physician's orders [REDACTED]. This was completed before the evening meal on [DATE]. - Speech therapist educated all staff on safe swallow techniques and aspiration prevention. This began with staff present evening shift [DATE] and will continue until all staff members have been educated prior to their next scheduled shift. - Speech therapist educated all staff to ensure meal trays are checked against the meal ticket to ensure the ordered diet is provided and any modifications and setup assistance is indicated and provided. This began with staff present evening shift [DATE] and will continue until all staff members have been educated prior to their next scheduled shift. - Speech therapist in conjunction with the DON educated nursing staff on level of supervision per speech therapy recommendations for residents who are at risk for aspiration during meals. This began with staff present during the evening shift [DATE] and will continue until all staff members have been educated prior to their next scheduled shift. - All residents with newly identified risk for aspiration or newly admitted with risk for aspiration will be supervised during meals per speech therapist recommendations. - The facility will audit all residents at risk for aspiration at all meals to ensure that they are supervised. This audit will be presented to the QAPI (quality assurance process improvement) committee on a monthly basis to determine that supervision is in place. The NHA, DON, and district director for clinical services (DDCS) were notified on [DATE] at 10:32 a.m. that the immediate jeopardy had been removed effective [DATE] at 10:28 a.m. Deficient practice remained at a G (actual harm for one resident) level. II. System failures Interviews with nursing staff and facility leadership demonstrated that although the facility was aware they had residents who did not adhere to their modified diets, the facility did not have a mechanism to assess, care plan, or provide interventions to mitigate the additional risk. Certified nurse aide (CNA) #2 was interviewed [DATE] at 3:12 p.m. She said she knew there were residents in the facility who preferred foods outside of their texture modifications, and said the facility honored those preferences. She said she had not received training related to what additional supervision, set-up assistance, or cueing was required in those cases. The speech therapist (ST) was interviewed on [DATE] at 1:28 p.m. She said she tried to liberalize the texture modifications to encourage intakes, but said she had very specific instructions for the liberalization, such as additional set-up assistance or increased cueing, that needed to be provided. She said many residents also required visual aids to help them complete a safe swallow. The ST said the dietary modifications were supposed to appear on the resident's tray card to prompt the CNAs to do the additional set-up, however, she said this was not happening. She also said the cue cards/visual aids she made for the residents had been removed, and as a result, the residents did not have access to the reminders needed for a safe swallow. The DON and DDCS were interviewed on [DATE] at 3:49 p.m. They said they were aware of three residents presently in the building who requested and were served foods outside of their ordered textures, including resident #3. They said these preferences were honored based on resident choice, and said education was provided to the residents about the risk; however, they said they did not have waivers in place to illustrate resident understanding. Regarding supervision during meals, they said the facility offered supervision in the dining room, but did not provide supervision other than occasional check-ins to residents who chose to eat in their rooms, even if they required increased supervision, or were eating foods that placed them at an increased risk of choking. III. Resident #2 Resident #2, age under 60, was admitted on [DATE]. According to the [DATE] physician orders, [DIAGNOSES REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) of 14 of 15. She did not receive any modified texture diets during the assessment. Record Review: A review of the resident's medical record demonstrated the resident had an established history of dysphagia, and had been placed on a modified diet to reduce her risk of aspiration. The record demonstrated the resident was not compliant with the modified texture; however, no additional interventions were implemented to address the increased risk posed by her noncompliance. The resident's care plan for nutrition, dated [DATE] and updated [DATE], indicated the resident was to have her meat cut into small pieces, and was not to receive tough, chewy, or stringy food. The care plan did not clarify the level of supervision required. The resident's care plan for activities of daily living (ADLs), dated [DATE], did not discuss the level of set up assistance or supervision needed with eating. No care plan was developed related to the resident's aspiration risk, or to address the resident's non-compliance with her ordered texture modifications. A nursing note dated [DATE] at 4:50 p.m. indicated the resident had eaten a Twizzler (licorice candy) that she had difficulty swallowing. A consult with speech therapy was ordered. The note indicated at the time of the incident, the resident had orders for a mechanical soft diet. A care conference note dated [DATE] indicated the resident often ate her meals in her room. A speech therapy discharge assessment dated [DATE] indicated the resident was discharged from speech therapy with orders to continue the modified texture. The note indicated that with the modified texture (food cut up into bite sized pieces, no stringy or chewy foods) the resident was able to perform sufficient airway protection, but still required cues to do so 20% of the time. The resident required supervision for eating, and the note indicated the resident's posture and muscular coordination fluctuated with her disease process and if she was tired. -The note documented the resident was able to safely masticate the modified texture diet (see order above), but required her visual cue card to follow the safe swallow strategies during intake. The note indicated the resident had a tendency to take large bites and did not follow a technique of alternating solid food with liquid food. -The note indicated the resident's prognosis was good if the staff were consistent with the recommendations. A nursing note dated [DATE] at 7:38 p.m. indicated the resident had been found in her room during dinner, unresponsive and not breathing. The note indicated a mouth sweep was performed and there was food in the resident's mouth. The nurse called 911 and was instructed to initiate cardiopulmonary resuscitation (CPR), which continued until the resident was discovered to have a do not resuscitate order. The resident was pronounced dead at 6:05 p.m. A review of the ADL documentation on [DATE] demonstrated the resident had required supervision and cueing during lunch. No documentation was present to demonstrate what level of assistance, if any, had been provided during dinner. Interviews: The speech therapist (ST #1) was interviewed on [DATE] at 1:28 p.m. She said the resident had been referred to her initially with swallowing difficulties related to her MS. She said the resident had initially had orders for a mechanical soft diet, but did not like the ground meat. As a result, they had worked on compensatory techniques, including taking small bites and alternating between solid food and a drink to reduce the risk. The ST said this had allowed the resident to be on a modified regular diet, in which meat and other items that were difficult to chew were cut into small bite size pieces. She also said the resident was supposed to avoid anything that would be chewy or stringy, as it increased her risk for aspiration. -In regards to the level of supervision required, the ST said the resident required distant supervision when she followed her modified texture recommendations. She said the resident also required a visual cue card to remind her to use her compensatory strategies and to prompt her to complete a safe swallow. -The ST said there had been concerns with the staff follow through on the interventions put in place to facilitate the resident safely eating the upgraded texture. She said the resident's cue card had been removed due to privacy concerns, leaving her without a visual prompt to aid in safe swallowing. She also said the resident had verbalized to her on multiple occasions that the CNA staff did not cut up her food as required. She also said the resident usually ate dinner in her room due to being tired, and did not receive the appropriate level of supervision as a result. The ST said this had been concerning because the resident had more difficulty with swallowing when fatigued. -The ST confirmed the resident had passed away while eating unsupervised in her room and said she had food in the back of her throat at the time. The DON and the DDCS were interviewed on [DATE] at 2:10 p.m. -The DON said the resident had been found in her room slumped over in her chair, unresponsive and not breathing. She said the resident did have MS, but her death was unexpected. The DON did not offer a purported cause of death, but said the facility had done a mouth sweep which had indicated there was food in her mouth. -The DON said the coroner had not requested an autopsy, and the facility had not conducted an internal investigation to determine the circumstances around the resident's death. The health information manager (HIM) was interviewed on [DATE] at 3:00 p.m. She said she had been the cart nurse on the hall at the time of the resident's passing. She said one of the CNAs had come to find her and told her the resident was unresponsive. She confirmed the resident had been eating unsupervised in her room at the time, and said she had done a mouth sweep which involved sticking her fingers into the resident's mouth and removing any food debris. She said there had been a flat oval of intact food which she illustrated with her hand to be approximately an inch and a half in diameter, lodged in the back of the resident's throat. -The HIM said the resident did not have a history of pocketing (retaining a portion of chewed food in the cheeks), but said that she did have difficulty swallowing, and would often cough or gag on food. She said the resident had some food modifications to help her swallow, but said she often declined them. -The HIM said the facility's usual supervision for residents at risk for aspiration was to provide additional supervision in the dining room. However, she said the resident often ate her dinner in her room. She said when this happened, it would make sense for the staff to provide more frequent check-ins on the resident than they otherwise would to ensure her safety, especially if she were eating foods that fell outside of her approved texture modifications. However, she said she was not aware of any guidance to do so. She said the resident did not have a cue card in her room the night of her death. CNA #2 was interviewed [DATE] at 3:12 p.m. She said the resident had MS, and had difficulty speaking and swallowing. She said the resident usually ate dinner in her bed, and when asked if she would like to go to the dining room, she would say she was too tired. The CNA said she had delivered the tray the night the resident had passed away. She said the resident had ordered a quesadilla, and it had not been cut up beyond the three large triangles a quesadilla would normally be cut into. -The CNA said she had not provided any additional set-up assistance to the resident, and had not been instructed to provide any kind of supervision or check in during meals to the resident. When asked if the resident had a cue card available to provide reminders to take small bites, or drink while eating, the CNA said the only card in the room was a list of foods she was not supposed to eat that was posted on the wall. -The CNA said another CNA, who was not scheduled to work that day, had actually found the resident, and had run and gotten a nurse. She said the nursing staff had been told the resident had choked. The DON and DDCS were interviewed on [DATE] at 3:49 p.m. They said the resident had not had a barium swallow test conducted to determine her ability to manage the upgraded texture. The facility's medical director (MD #1) was interviewed on [DATE] at 4:00 p.m. He said the facility had conversations about the resident's texture modifications, and he remembered she required her foods to be cut into small pieces to help her swallow, however, he did not have access to his notes. The MD said for someone with dysphagia, consuming textures that were above the texture they had been assessed to be able to swallow increased the risk of aspiration, which he said could lead to weight loss, pneumonia, and choking. A representative from the county coroner's office was interviewed on [DATE] at 12:39 p.m. He said the coroner did not open an investigation in a case where a person died under the care of a physician unless circumstances were reported that would indicate neglect, or if it were requested. He said the facility had reported the resident's death, but said the resident had wanted her body to be donated. He said he was not informed of the circumstances of the resident's passing. IV. Resident #3 Resident #3, age under 70, was admitted on [DATE]. According to the [DATE] physician orders, [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident was cognitively intact with a brief interview for mental status of 15 of 15. She received set up help and supervision for eating. However, a review of the speech therapy assessments from [DATE] to [DATE] indicated cognitive impairment as a component of the resident's swallowing difficulty. The resident was self-identified by the facility as requiring a mechanical soft texture, however, the MDS indicated she did not receive texture modifications during the assessment. Record Review: A review of the speech therapy notes and assessments indicated the resident was referred for speech therapy on [DATE] following an increase in coughing, a significant weight loss, and an overall decline in strength. The initial speech therapy assessment, dated [DATE], indicated the resident had impaired function/sensation in her tongue, mild to moderate impairments in the strength, range of motion, and coordination in her jaw, and impairments in cognitive function and communication. The resident was assessed with [REDACTED]. A late entry physician's orders [REDACTED]. However, there was no corresponding speech therapy assessment from the time period indicated, and the [DATE] and [DATE] speech therapy notes both indicated the resident continued on orders for, and was evaluated with, a mechanical soft texture. The resident continued to receive speech therapy until [DATE]. The discharge assessment indicated the resident was to receive food with the mechanical soft texture. At the time of discharge, the resident was able to safely and efficiently swallow the mechanical soft texture 90% of the time, and was recommended to continue on distant supervision for that texture. No evaluation of her ability to safely swallow solid foods without texture modifications was present. The care plan for nutrition, dated [DATE] and updated [DATE], indicated the resident had dysphagia. Approaches included providing the resident with her diet as ordered. The care plan did not describe the texture orders or provide guidance or clarification related to texture modification or supervision. A care plan for the resident's developmental disability indicated tasks were to be broken down, and reminders and encouragement provided, as well as consistent and repetitive instructions to facilitate the resident's ability to learn tasks. The care plan for ADLs, dated [DATE] and updated [DATE], indicated the resident required set up assistance and some supervision for eating. The approaches were not updated after the resident was placed on a modified texture. The resident's care plan indicated she had impaired cognitive function and decision making capability. No care plan was created related to the resident's aspiration risk due to dysphagia, or to address her preference for foods outside of the ordered modified texture (see DON and DDCS interview above and observations below). Observations: Resident #3 was observed on [DATE] beginning at 11:56 a.m. She was in her room, and was lying in her bed. No cue/visual aid cards were observed in her room. The resident had not received a lunch tray. The resident lived on the far side of the room. Her privacy curtain was out, and the resident's bed, bedside table, and wheelchair were not visible from the hallway. A continuous observation was initiated. At 12:58 p.m. CNA #1 was observed removing a covered dish from the cart. The dietary manager took the tray in, and left the room within 15 seconds. After the resident's tray was delivered, a total of four nursing staff (CNA #1, CNA #4 the DON, and CNA #3) were observed passing the resident's room; none of the staff looked into the room or entered to check in on the resident. At 1:22 p.m. the resident left her room and wheeled herself down the hall in her wheelchair. She went to a water tank and filled a cup with water. She appeared to be chewing. CNA #3 told the resident she wanted to change her sheets and asked her not to get back into her bed. At 1:24 p.m. the resident returned to her room. At 1:30 p.m. the resident's room tray was observed to contain a cheeseburger, with lettuce, tomato, and onion as a garnish. No packets of ketchup, mustard, or mayonnaise were observed. The burger was whole and had not been cut. Three bites were taken from one end of the burger. A meal card was observed on the tray which indicated that the resident was to receive a mechanical soft diet. No additional instructions related to texture were present. The resident was observed to cough multiple times. Interviews: The speech therapist (ST #1) was interviewed on ,[DATE] at 1:28 p.m. She said the resident had been referred to her caseload early in the year when she began to experience difficulty swallowing. She said the resident had been approved for a mechanical soft texture, and required distant supervision with that texture. She said the resident did not like the mechanical soft texture and would not eat it, and as a result had begun to lose weight. In an effort to maintain nutritional integrity, she had approved hamburgers (which the resident liked) as long as they were cut in half and had a lot of ketchup on them. She confirmed the hamburgers were not a mechanical soft texture and that the resident had not been assessed for them. -The ST said it had been difficult to ensure good communication and follow through on the resident's needs with the nursing staff. She said the additional texture modifications were not on the dietary card and there was not a reliable mechanism to communicate additional set-up instructions to the staff. She confirmed the staff were not consistent with cutting the resident's hamburgers, putting the ketchup on, or ensuring she was seated upright in her chair. CNA #1 was interviewed on [DATE] at 1:57 p.m. She said texture modifications were usually on the meal ticket, or if there were additional instructions, they should be in the chart. She said she had not been instructed to cut the resident's hamburger or provide ketchup. She said she was not sure how often to check in with residents with room trays during meals, and said she checked in on every resident with a room tray every 20 minutes or so. She said if a resident required additional supervision or cueing she would expect it to be in the resident's chart. The DON and DDCS were interviewed on [DATE] at 3:49 p.m. They said the resident had not had a barium swallow test conducted to determine her ability to manage the upgraded texture. The facility's medical director (MD #1) was interviewed on [DATE] at 4:00 p.m. He said for someone with dysphagia, consuming textures that were above the texture they had been assessed to be able to swallow increased the risk of aspiration, which he said could lead to weight loss, pneumonia, and choking.

Based on observations, record review and interviews, the facility failed ensure five of 23 sample residents (#3, #7, #8, #11 and #12) received care consistent with professional standards of practice, to prevent pressure ulcers from developing unless unavoidable, and once pressure ulcers developed, failed to ensure the residents received necessary care and treatment to promote healing, to prevent infection and to prevent new ulcers from developing. Specifically, the facility failed to: -For resident #3 - Assess, monitor and implement interventions to promote healing and prevent infection and deterioration of an existing pressure injury to a stage IV ulcer, and timely identify and prevent the resident from acquiring additional pressure ulcers on his right heel and coccyx. Resident #3 was discovered with two painful pressure ulcers, one unstageable on his coccyx and one a stage III on his right heel that had not been reported to nursing staff until survey. -For resident #7 - Treat pressure injuries per physician's orders [REDACTED]. -For resident #12 - Assess, monitor and implement interventions to address the resident's risk for pressure ulcers from a mechanical device, oxygen tubing. Staff responsible for pressure ulcer management was unaware of the resident's history of skin breakdown from the tubing. -For resident #11 - Assess and monitor existing pressure ulcers on the resident's heels; a previously healing ulcer was currently unstageable. Staff responsible for pressure ulcer management was unaware of the resident's ulcers. -For resident #8 - Consistently implement physician orders [REDACTED]. The facility's failure to ensure residents #3, #7, #12, #8, and #11 received care consistent with professional standards of practice to prevent pressure ulcers from developing, and once pressure ulcers developed, received necessary care and treatment to promote healing, to prevent infection and to prevent new ulcers from developing created a situation of immediate jeopardy for serious harm. I. Immediate jeopardy A. Imposition of Immediate Jeopardy On 2/10/17 at 4:20 p.m., the nursing home administrator (NHA), director of nursing (DON), clinical nurse consultant (CNC) and the divisional director of operations (DDO) were informed by the Colorado Department of Public Health and Environment (CDPHE) the facility's pattern of failure to prevent pressure ulcers from developing, and once pressure ulcers developed, to provide necessary care and treatment to promote healing, to prevent infection and to prevent new ulcers from developing created a situation of immediate jeopardy for serious harm. B. Facility Response to Immediate Jeopardy On 2/10/17 at 5:11 p.m., a plan was submitted by the facility to CDPHE. It read: -Facility to conduct head to toe skin assessments on every resident to inspect for pressure ulcers. If an issue was identified, a SBAR (situation, background, assessment, recommendation) would be completed, treatment orders would be obtained, preventative interventions would be implemented and the care plan would be updated. This began on 2/10/17 and would be completed on 2/10/17. A licensed nurse would complete the skin assessments with a registered nurse (RN) performing wound staging. The resident care management director or designee was responsible for updating the care plan of existing wounds and those would be updated by 2/10/17. The resident care management director would be responsible for updating the care plan on an ongoing basis. -The weekly pressure ulcer record would be updated by a registered nurse manager. Existing wound pressure ulcer sheets would be in place by 2/10/17. If a new wound was identified, a registered nurse manager would be responsible for implementing a pressure ulcer record. -All nurses would receive education if a pressure ulcer was identified, an SBAR must be completed, the wound to be measured, appropriate notifications should be made, it would be placed on the 24-hour report, treatment orders would be obtained, preventative interventions would be implemented (i.e. heel floating, appropriate mattress, etc.), and a weekly pressure ulcer sheet would be implemented. This education would begin on 2/10/17 during the evening shift and would continue until all nurses have received education prior to working on the floor by the staff development coordinator (SDC) or designee. The family would be notified within 24 hours. -All pressure ulcers would have an order for [REDACTED]. -If a wound was identified, the director of nursing (DON) would be immediately contacted via phone as the point person. The DON would then verify the pressure policy was followed. The DON would then ensure appropriate prevention equipment had been implemented or ordered. All pressure ulcers would be followed by the interdisciplinary team (DON, SDC, ADON, RCMD, RD, and SSD) on a weekly basis. The wound orders would be reviewed for completeness and implementation on the Medication Administration Record [REDACTED]. -The DON/RN designee would be the wound nurse. The DDCS would be responsible for training these wound nurses on procedures and expectations. The training would begin on 2/10/17. -Any resident with a Braden score of twelve or below, identified as a high risk would have preventative interventions in place. The assigned nurse would be completing the Braden scale upon admission, quarterly, annually and with a significant change. The assigned nurse would put an intervention into place for anyone identified as high risk by the end of the shift and obtain orders as necessary. The registered nurse manager team would ensure the Braden scale was done as required and follow-up as necessary that appropriate interventions were implemented and orders were in place. -Upon hire and during facility orientation the SDC or designee would train new licensed nurses on the procedures for pressure ulcers. Upon the use of nurses from a sister facility who were working at this facility, the SDC/designee would ensure education could be completed with them prior to working their shift. If the SDC was not present, the DON would be responsible for the education. -RCS staff would receive education on what to do when changes of skin condition occur and implementing certified nurse aide (CNA) interventions such as repositioning. The SDC would be responsible for conducting the training which would immediately begin on 2/10/17 during the 2 p.m., to 10 p.m., shift. The RCSs would not be allowed to begin their shift until this training had occurred. C. Removal of Immediate Jeopardy On 2/10/17 at 5:30 p.m., the NHA and CNC were notified the above plan was accepted and the immediate jeopardy was removed. However, based on observations, record review and interviews, the deficient practice remained at a G level, actual harm that is isolated. II. Facility Policies and Expectations A. Policies The facility's skin management policy revised on 8/12 read in part: Residents who are at risk or with wounds and/or pressure ulcers and those at risk for skin compromise are identified, assessed and provided appropriate treatment to encourage healing and/or integrity. Ongoing monitoring and evaluation are provided to ensure optimal resident outcomes. A pressure ulcer was defined as any lesion caused by unrelieved pressure resulting in damage of underlying tissue. The staging classification is consistent with the national pressure ulcer advisory panel (NPUAP). B. Expectations The Director of Nurses (DON) and nursing home administrator (NHA) were interviewed on 2/9/17 at 12:27 p.m. and 12:44 p.m. respectively. Both stated it was their expectation staff follow facility policies and physician orders. III. NPUAP Staging According to the NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. 16 Feb. 2017. http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages, a pressure injury is localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device. Tthe updated staging system includes the following definitions: -Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence-associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). -Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. -Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. -Medical Device Related Pressure Injury: Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. IV. Resident failures A. Resident #3 1. Resident Status on Admission Resident #3, age 93, was admitted on [DATE]. According to the admission record sheet, the resident had [DIAGNOSES REDACTED]. Although review of the resident's admission minimum data set ((MDS) dated [DATE] and the quarterly MDS dated [DATE] documented the resident had no pressure ulcers, according to the Assistant Director of Nurses (ADON) on 2/9/17 at 10:37 a.m., the resident entered the facility with an ulcer, stage II, on his right lateral ankle. The skin-weekly pressure ulcer records (SWPURs) documented the onset date of ulcer as 1/22/16. 2. Deterioration of right ankle pressure ulcer after admission Record review revealed the resident's ulcer on his right lateral ankle deteriorated after admission; it became infected in early December 2016 and subsequently increased in size and depth with necrosis and another infection. Record review revealed the ulcer, a stage II on admission, a stage III on 12/14/16, was a stage IV when observed on 2/9/16. Specifically: a. Record review -A physician note dated 12/6/16 at 10:41 a.m., read this was an acute physician visit for an open wound on the right ankle managed by doctor (named). A culture and sensitivity returned and noted Proteus mirabiolis (gram-negative facultative anaerobic rod-shaped bacterium) with a sensitivity to [MEDICATION NAME]: medications were ordered for ten days. The resident was reported stable with respect to pressure ulcer of unspecified ankle and unspecified stage. The resident had a right lateral ankle wound and was followed by a wound team. The assessment and plan noted a pressure ulcer of unspecified ankle and unspecified stage. Continue to monitor for resident's pressure ulcer of unspecified ankle. Administer [MEDICATION NAME] 500/125 tablet orally twice a day for ten days. -The skin-weekly pressure ulcer record (SWPUR) dated 12/14/16 at 1:50 p.m., noted a wound to the right outer ankle with an onset date of 1/22/16. The pressure ulcer measurements were 2.0 x 1.2 x 0.3 centimeters (cm). The wound was a stage III. The description of the site was 20 % skin, 10% slough and 70% granulation. There was no undermining or tunneling. The wound bed had normal skin appearance with a small amount of serosanguineous exudate. Change the treatment plan to silver alginate cut to fit, non-adhesive foam dressing, secure with kerlix and change twice a day. The physician and the family were notified. -The SWPUR dated 12/21/16 (not timed) noted the right lateral malleolus measurements were 2.1 x 1.0 x 0.3 cm deep with no slough. New orders were to continue treatment. -The SWPUR dated 12/29/16 at 11:08 a.m., noted a wound to the right outer ankle with an onset date of 1/22/16. The pressure ulcer measured 2.1 x 1.0 x 0.3 cm and was not staged. There was moderate serous drainage, 80% granulation tissue, and 20% skin. The site had improved by decreased infection, decreased surface area, and decreased slough. There was no undermining or tunneling. The wound bed had normal skin appearance with moderate serious drainage. There was no odor present. Continue with the current treatment plan. Physician and family were notified. -The SWPUR dated 1/4/17 (not timed) noted a right lateral malleolus wound measuring 3.0 x 1.9 x 0.1 cm with new orders to continue treatment. -The SWPUR dated 1/11/17 at 11:20 a.m., noted a wound to the right outer ankle with an onset date of 1/22/16. The pressure ulcer measured 2.7 x 2.0 x 0.4 cm and was not staged. The description of the site noted heavy serous drainage, 85% granulation tissue and 15% skin. The site had deteriorated due to excess moisture. There was no undermining or tunneling. The wound bed had normal skin appearance with moderate serous exudate. There was no odor present. The treatment was skin prep twice daily to the periwound, silver alginate twice daily and cut to fit wound with foam twice daily. Physician and family were notified. -The wound care specialist evaluation (WCSE) dated 1/11/17 (not timed) noted wound to the right ankle with a duration of 214 days. The wound measured 2.7 x 2.0 x 0.4 cm with a surface areas of 5.40 cm squared. The periwound radius had maceration with heavy serious exudate. There was 15% thick adherent devitalized necrotic tissue. Granulation tissue was 85% and wound progress had deteriorated. Assessment and plan of care recommendations were surgical excisional debridement and off load wound. Infection present, which would likely worsen if surgical excisional debridement was not performed. Evaluation of wound by the care specialist within seven days with further intervention as indicated. Discontinue skin prep once daily to periwound, collagen with silver once daily, cut to fit wound, foam once daily. Add skin prep twice daily to periwound, silver alginate twice daily and cut to fit wound with foam twice daily. Wound deteriorated due to excess moisture. -The SWPUR dated 1/18/17 (not timed) noted right lateral malleolus wound measuring 2.9 x 1.8 x 0.2 cm with new orders to continue treatment. -The SWPUR dated 1/25/17 (not timed) noted wound to right lateral malleolus. -The SWPUR dated 2/1/17 (not timed) noted a right lateral malleolus wound measuring 3.1 x 1.5 x 0.3 cm with new orders to continue treatment. No stage was documented. -The SWPUR dated 2/9/17 at 11:57 a.m. (during survey), noted the site of assessment for pressure was the right malleolus. The measurements were 3.6 x 2.0 x 0.3 cm stage IV. There was no undermining. The wound bed had red granulated tissue with some noted yellow slough at 12 and 6 o'clock. There was a moderate amount of serosanguineous drainage with no odor present. The surrounding skin away from the wound edges was macerated. The resident did have pain and new orders to increase pain medication was given. Specialty treatments were airbed and wheelchair cushion. The resident's response to current treatment was deterioration. The ulcer was larger in size from the last assessment with maceration and increased pain at site. The physician and family were notified. b. Observations of right lateral ankle ulcer The resident's right lateral ankle ulcer was observed on 2/9/17 at 10:37 a.m. during wound care. Staff members present included the ADON/licensed practical nurse (LPN), the staff development manager (SDM/registered nurse (RN) and nurse practitioner #1. The resident was transferred into bed and the boot on his right foot was removed. The resident's right lateral malleolus had an [MEDICATION NAME] bandage in place. The bandage was removed and had a moderate amount of serosanguinous drainage on it. The wound was covered with a piece of calcium alginate cut to fit the wound bed. The alginate was saturated with exudate. The dressing was removed to reveal the wound beneath it, which appeared as a stage IV pressure ulcer with tendon exposed. The wound had no signs of infection and the bed had red granulation tissue with a small amount of slough at the top portion of the wound. The right side of the wound was macerated. The remaining periwound tissue was red but blanchable. The ADON confirmed the wound, upon admission a stage II, was today a stage IV. c. Facility's response to the resident's right lateral ankle ulcer (1) The facility provided documentation (manufacture's product specifications) the resident's bed mattress was a pressure redistribution mattress. The mattress had a combination of multi-layered die cut and memory foam for therapeutic pressure redistribution. (2) A physician's orders [REDACTED]. (3) A nutrition note dated 1/18/17 at 14:51 (2:51 p.m.) read the resident continued on fortified diet, extra meat at meals and four ounces of house supplement orally three times a day to provide additional kilocalories and protein to aid in weight stabilization and healing. (4) Review of the SWPUR above indicated orders for treatment of [REDACTED]. d. Failures in facility's response to the resident's right lateral ankle ulcer (1) Failure to develop a resident-specific care plan to promote healing Although admitted with a pressure ulcer (see above), and assessed at high risk for pressure ulcer development on 1/23/16, 8/16/16, 11/29/16, the resident did not have a care plan to address his pressure ulcer and risk for development of additional pressure ulcers on or after admission, until survey (2/8/17 - 2/10/17). This care plan read: The resident had potential/actual skin issues related to right lateral ankle wound, left buttock wound, right heel wound, confusion, diabetes mellitus, [MEDICAL CONDITION], muscle wasting, atrophy, decreased mobility/weakness, weight loss, frequent bowel and bladder incontinence. Interventions included: -Air mattress to bed. Multi podus boot to right foot as the resident would allow; resident frequently refuses a multi podus boot. Turn and reposition frequently to decrease pressure; resident frequently declines turning and repositioning. Encourage the resident to elevate his right lower extremity at rest. Keep linens clean, dry and wrinkle free as able to prevent areas of pressure. Monitor areas of skin impairment for signs/symptoms of infection as evidenced by redness, warmth, swelling, purulent drainage, elevated temperature and report to the primary care physician with changes. -Monitor for [MEDICAL CONDITION] noting location and degree of pitting and report changes to the primary care physician. Notify physician of changes in wound or emerging wounds. Observe wound healing. Pressure reducing pad applied to wheel chair. Provide wound care/preventative skin care per orders. Skin checks weekly per facility protocol, document findings. -Staff to provide toileting, peri-care and pad changes with incontinent episodes and as needed. Apply barrier creams with cares. When prosthesis to left lower extremity was in use check for proper fit monitoring skin for areas of friction/rubbing and report to charge nurse as needed. (2) Failure to implement order for a multi-podus boot on his right heel. Review of the orders administration (O-A) revealed the order for the resident's boot (see above) was not consistently implemented. -The orders administration (O-A) by a nurse dated 1/15/17 at 18:32 (6:32 p.m.) noted to apply multi podus boot while in bed to right foot every evening shift for wound on right foot: none. -The O-A by a nurse dated 1/24/17 at 23:58 (11:58 p.m.) noted to apply multi podus boot while in bed to right foot every evening shift for wound on right foot: none. -The O-A by a nurse dated 1/29/17 at 1:06 p.m., apply to multi podus boot while in bed to right foot every evening shift for wound on right foot: none. -The O-A by a nurse dated 1/30/17 at 00:40 a.m., noted to apply multi podus boot while in bed to right foot every evening shift for wound on right foot: none. -The O-A by a nurse dated 2/2/17 at 20:21 (8:21 p.m.) noted to apply multi podus boot while in bed to right foot every evening shift for wound on right foot: none. The district clinical director (DCD) was interviewed on 2/10/17 at 5:57 p.m. He said according to the DON's investigation, there was no podus boot available when the nurse used the word none in their notes when documenting on the use of the podus boot to the right foot every evening shift for a wound on the right foot. The resident was observed lying in bed on 2/8/17 at 9:15 a.m., and 9:57 a.m. He had his eyes closed and two pillows were under his head. He had his covers pulled to his chest. He wore a long sleeve blue shirt with the sleeves visible. No podus boot was observed in the room. (3) Failure to implement orders for wound treatments The physician's orders [REDACTED]. Cover with foam, secure with transparent dressing twice daily and as needed. Initial and date each dressing change. The treatment administration record (TARs) dated 1/1/17 and 2/1/17 noted right lateral malleolus ankle cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and as needed. Initial and date each dressing change two times a day for wound management (order date of 1/14/17 and discontinued dated of 2/8/17). The TARs noted 16 dressing changes were not performed (the boxes were marked with an X as well as an eight (8) other/see progress note) as physician ordered. The following dates/times the wound dressings were not changed: -1/19 at 8:00 a.m., -1/22 at 8:00 a.m., -1/23 at 8:00 a.m., -1/24 at 8:00 a.m., and 4:00 p.m., -1/26 at 4:00 p.m., -1/27 at 8:00 a.m., -1/28 at 8:00 a.m., -1/29 at 8:00 a.m., -2/1 at 8:00 a.m., -2/2 at 4:00 p.m., -2/3 at 8:00 a.m., and 4:00 p.m., -2/5 at 8:00 a.m., and -2/6 at 8:00 a.m., and 4:00 p.m. Review of the O-A revealed the order was not consistently implemented. -The orders-administration (O-A) note by a nurse dated 2/6/17 at 23:52 (11:52 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management dressing changed on days. There was no nursing documentation this computer generated order was completed. -The O-A note by a nurse dated 2/6/17 at 13:38 (1:38 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management. There was no nursing documentation this computer generated order was completed. -There was no O-A note for the dressing change scheduled at 2/5/17 at 8:00 a.m. -There was no O-A note for the dressing change scheduled at 2/3/17 at 8:00 a.m., and 4:00 p.m. -The O-A note by a nurse dated 2/2/17 at 20:21 (8:21 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management done on days. There was no nursing documentation this computer generated order was completed. -The O-A note by a nurse dated 2/1/17 at 15:27 (3:27 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management. Wound rounds today. -There was no O-A note for the dressing change scheduled at 2/1/17 at 8:00 a.m. -There was no O-A note for the dressing change scheduled at 1/29/17 at 8:00 a.m. -There was no O-A note for the dressing change scheduled at 1/28/17 at 8:00 a.m. -There was no O-A note for the dressing change scheduled at 1/27/17 at 8:00 a.m. -The O-A note by a nurse dated 1/26/17 at 21:26 (9:26 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management. Not done related to somnolence (sleepiness). -There was no O-A note for the dressing change scheduled at 1/24/17 at 8:00 a.m. -The O-A note by a nurse dated 1/24/17 at 23:58 (11:58 p.m.) right lateral malleolus ankle- cleanse site, apply skin prep to periwound, apply cut to fit silver alginate to wound bed. Cover with foam, secure with transparent dressing twice daily and prn. Initial and date each dressing change two times a day for wound management done on day shift. There was no nursing documentation this computer generated order was completed. -There was no O-A note for the dressing change scheduled at 1/23/17 at 8:00 a.m. -There was no O-A note for the dressing change scheduled at 1/22/17 at 8:00 a.m. -The O-A note by medical records dated 1/19/17 at 9:39 a.m., noted no side effects and wound care team would do cares. -There was no O-A note for the dressing change scheduled at 1/19/17 at 8:00 a.m. The director of nursing (DON) was interviewed on 2/9/17 at 12:08 p.m. She confirmed the new wound dressing order starting on 1/14/17 read to change the dressing to the resident's right ankle twice a day. The DON was interviewed again on 2/9/17 at 12:27 p.m. She said the computer system repeated the physician order. She said if there was no additional nursing documentation, it was the system repeating the order. She said there needed to be nursing documentation of the dressing change in the note. She said when you click on the chart codes the system took the writer to a progress note and the physician's orders [REDACTED]. She said the nurse should type after the note what they did. She reviewed the O-As above and agreed there was missing documentation the dressing changes were completed as physician ordered. She said the dressing changes should have been completed as physician ordered, that was her expectation. 3. Discovery of unidentified, painful pressure ulcers during survey a. 2/8/17 Observations and Staff Interview: At 9:25 a.m., LPN #2 said was interviewed. She said the resident did not want to get up this morning; he wanted to be left alone. She said he requested pain medications and she administered them to him. She said she also gave him a health shake. She said the resident had a pressure ulcer on the malleolus of his right foot. At 10:36 a.m., certified nurse aide (CNA) #4 was interviewed. She said the resident had a pressure ulcer on his heel and one on his coccyx. The CNA lifted up the sheet covering the resident's lower extremities and there was a bandage on the resident's lateral right ankle. There also appeared to be a large dark scabbed area on the heel of the resident's right foot. There was no bandage on this area. At 10:42 a.m., the CNA said she repositioned the resident at 10:36 a.m. and the resident did not have a bandage on his coccyx wound. The CNA said she was sure the nursing staff was aware of the resident's heel and coccyx wounds. At 10:40 a.m., the nurse surveyor requested to see the resident's coccyx wound with LPN #2. At 11:34 a.m., LPN #2 was approached and a request was made to observe the resident's coccyx wound. LPN #2 said she was just notified by a CNA of an issue with the resident's bottom. She said she observed the wound, received orders from the nurse practitioner and had put a dressing on the wound. Observations revealed there was a 4 x 4-exuderm dressing on the resident's coccyx with a visible dark wound in the center. The LPN said the wound measured 1.0 x 2.5 cm in size with no depth. The wound was scabbed over with a scant amount of bloody exudate. -The LPN said the wound was definitely a pressure ulcer and the wound team would stage the ulcer. The LPN said

Based on observations, 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 (#2, #3, #5, and #8) out of 23 sample residents. Specifically: -The facility failed to ensure resident #3 and #2's pain was assessed and/or managed; at times, pain medication was not available for administration as ordered. Resident #3 expressed pain during wound treatments on 2/8/17, but staff did not stop his treatment or address his pain until completion of his wound care. Record review also revealed resident #3's routine pain medication was unavailable for 11 administrations from 1/31 to 2/3/17, during which time his pain was infrequently assessed. -The facility failed to ensure resident #5's skin condition was assessed and resident #8's urinalysis was timely obtained. I. Pain Management A. The facility pain management policy revised on 8/12 read: -In item (5), each resident identified for pain would have a pain management care plan. The care plan would have individualized interventions related to the resident's individual control of pain management. The care plan should include both pharmacological and non-pharmacological pain management interventions. Resident Care Specialist (RCS) assignment sheet/care Kardex updated if appropriate. -In Item (6), the licensed nurse would implement a medication administration record (MAR) for documentation of pain, medication, interventions and outcomes for all pain medications. -In Item (10), the staff will implement the care plan, monitor the resident and administer therapeutic interventions for pain if ordered. -Item (11), the licensed nurse when administering scheduled or routine pain medications will record the drug administration and the following information on the MARs; pain level using the Wong-Baker Faces 0-10 rating scale, administration of the routine pain medications and effectiveness of the routine pain medications. B. The facility's medication administration policy revised on 6/08 read: Resident medications are administered in an accurate, safe, timely and sanitary manner. The authorized personnel section noted medications are prepared, administered and recorded only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. The documentation section read record the name, dose, route and time of medication on the medication administration record (MAR). Initial the record after the medication was administered to the resident. C. The facility's pharmacy reordering policy revised on 1/12 read: -There were multiple ways to order medication from the pharmacy - via fax, via telephone and via (named) electronic refill system. Remember when ordering medication, it is your responsibility to do all you can to make sure residents receive the right medicine at the right time. Pay close attention to the processes involved and monitor to validate occurrence. If the medication was not available for administration due to a delay in ordering, we put the resident at risk . -The reordering procedures section read medication refills should be requested when a 3-5 day supply remains. This lead-time varies by pharmacy. The preferred method for ordering refills is by electronic refill (named). You may also call the pharmacy directly for a STAT (immediate) order for clarification on a recorder. -The ordering class II (CII) medications section read the drug enforcement administration (DEA) regulations only permit CII medications to be dispensed upon the receipt of a complete, signed order from the prescriber or pursuant to an oral emergency order from the prescriber that was immediately reduced to writing by the pharmacist and followed by a signed order from the prescriber within seven days. II. Failure to ensure resident #3 and #2's pain was assessed and/or managed; at times, pain medication was not available for administration as ordered. A. Resident #3 1. Resident Status Resident #3, age 93, was admitted on [DATE]. According to the admission record sheet, the resident had [DIAGNOSES REDACTED]. According to the 12/8/16 minimum data set (MDS), the resident had a brief interview for mental status score of 13 out of 15, indicating he was cognitively intact. The resident was not noted to have any behaviors or short/long term memory problems. The resident required extensive assistance from staff for bed mobility, transfers, dressing, toileting and personal hygiene. The resident was totally dependent on staff for bathing and required a one person physical assist. The resident was noted to have received a scheduled pain medication. The resident was at risk for developing a pressure ulcer. The resident had one stage II pressure ulcer. The resident also had one unstageable - slough and/or eschar pressure ulcer. The care plan, initiated 2/20/16, read the resident had a potential/actual pain related to a potential for pain in his bilateral shoulders, right ankle/foot and generalized discomfort. The interventions were observe for signs/symptoms of verbal and non-verbal indicators of pain at each medication pass and periodically. Monitor location, duration, type and intensity of pain and document as needed. Notify the physician of unrelieved pain. Provide diversion activities such as positioning, music, and television. Provide medication as ordered and document effectiveness results of the administered medication. The physician's orders [REDACTED]. Administration times, per the medication administration record (MAR), were documented as 8:00 a.m., 12:00 noon, 4:00 p,.m. and 8:00 p.m. The report also noted Tylenol tablet 325 mg administer two tablets (650 mg) by mouth every six hours as needed for pain/fever with a start date of 1/22/16. Resident #3 was observed in bed on 2/8/16 at 11:24 a.m. and in his wheelchair in the dining room on 2/10/17 at 1:26 p.m. He did not respond to questions regarding his pain. 2. Failure to address resident #3's pain a. Observations Wound care for resident #3 was observed on 2/9/17 at 10:37 a.m. The assistant director of nursing (ADON), staff development manager (SDM), and nurse practitioner (NP) #1 were present. The resident was treated for [REDACTED]. Throughout the evaluation and treatment, the resident moaned when he was repositioned or his right leg was moved. He verbally complained of wound pain twice, flinching and jerking back his leg when his wounds were touched. The SDM rubbed the resident's feet, stating she was trying to determine if the pain was from sensitive feet or from the wound on his foot; when she touched the wound on the resident's heel, the resident jerked and said the wound hurt. None the nurses nurses performing the wound treatments responded to the resident's verbal and nonverbal expression of pain; neither staff offered to stop treatment and provide pain medication until after the completion of wound care at 11:06 a.m. At that time, the ADON offered the resident Tylenol, which the resident accepted. b. Staff interviews The SDM and the ADON were interviewed during the wound care observation on 2/9/17 at 10:37 a.m. The SDM said she believed the resident's pain to be caused from the wound to his right ankle. The ADON said staff had noted an increase in the resident's pain. She said the resident's pain was causing the resident to not get out of bed. She said the nurse practitioner had written a new order to start a [MEDICATION NAME] pain medication patch and the new medication was due to be delivered that day. She said the resident currently was taking [MEDICATION NAME] 10/325 mg tablets routinely She said he had received [MEDICATION NAME] this morning prior to the wound care treatment. (See above; morning administration was scheduled for 8:00 a.m.) The DON was interviewed on 2/9/17 at 11:22 a.m. She said pain was managed during wound care by offering the resident pain medication prior to treatment. She said if a resident complained of pain during the treatment, nurses should ask the resident if he or she wants staff to stop and if he would like to take more pain medication and wait for the treatment to continue. She said resident #3 should have been offered pain medication during the observed treatment. 3. Failure to ensure the resident's pain medication was available and administered as ordered. Review of physician orders, medication administration records (MARs) and nursing order-administration notes in the progress notes revealed staff failed to ensure resident #3's pain was assessed and his routine medication for pain was available and administered as ordered from 1/31/17 to 2/3/17 (11 administrations). a. See above; the physician's orders [REDACTED]. b. The MARs, dated 1/1/17 and 2/1/17, noted an eight (8 other-see progress note) in the boxes as evidence the medication [MEDICATION NAME] Tablet 10-325 mg give one tablet by mouth four times a day for pain was not administered as physician ordered. The MARs also noted pain levels were not performed as evidenced by an X in the box correlating with the administration of the pain medication. The following dates and times noted when the pain medication was not administered: -1/31 at 1600 (4:00 p.m.) with no documented pain level scale, -1/31 at 2000 (8:00 p.m.) with no documented pain level scale, -2/1 at 8:00 a.m., with no documented pain level scale, -2/1 at 1200 (noon), with no documented pain level scale, -2/1 at 4:00 p.m., with no pain documented level scale, -2/1 at 8:00 p.m., with no documented pain level scale, -2/2 at 8:00 a.m., with no documented pain level scale, -2/2 at 1200 (noon) with no documented pain level scale, -2/2 at 4:00 p.m., a pain level of five out of ten was documented, -2/2 at 8:00 p.m., a pain level of zero out of ten was documented, and -2/3 at 8:00 a.m., a pain level scale of three out of ten was documented. c. The clinical record progress notes documented: -The orders-administration (O-A) note by a nurse dated 2/3/17 at 11:26 a.m., noted [MEDICATION NAME] Tablet 10-325 MG Give one tablet by mouth four times a day for pain: Awaiting delivery. -The O-A note by a nurse dated 2/2/17 at 17:21 (5:21 p.m.) [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Right ankle pain: on order. -The O-A note by a nurse dated 2/2/17 at 12:31 p.m., [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Awaiting delivery from pharmacy. -The O-A note by a nurse dated 2/2/17 at 9:58 a.m., [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Unavailable from pharmacy. -The O-A note by a nurse dated 2/1/17 at 20:08 (8:08 p.m.) [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. On order. -The O-A note by a nurse dated 2/1/17 at 16:14 (4:14 p.m.) [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Not given, waiting for delivery. Resident said he was not in pain at this time. -The O-A note by a nurse dated 2/1/17 at 7:49 a.m., [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Need new script. -The O-A note by a nurse dated 1/31/17 at 20:05 (8:05 p.m.) [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. Medication on order. -The O-A note by a nurse dated 1/31/17 at 17:48 (5:48 p.m.) [MEDICATION NAME] Tablet 10-325 MG. Give one tablet by mouth four times a day for pain. On order. The medication delivery sheet from the (named) pharmacy noted the [MEDICATION NAME] Tablet 10-325 mg (30 tablets) were delivered to the facility on [DATE] at 9:19 a.m. d. The director of nursing (DON) was interviewed on 2/9/17 at 10:22 a.m., and said it was her expectation that staff follow facility policies (see facility policies above). At 11:50 a.m. the DON reviewed the MARs for 1/1/17 and 2/1/17. -She agreed there was lack of documentation regarding the resident's level of pain. She said, usually, when nursing staff document an eight (8) in the box for administration, it meant the medication was not given. She acknowledged the boxes for the above mentioned medication times had eights in the boxes. She said if the resident had refused his [MEDICATION NAME] pain medication, it would be documented on the MAR. She agreed there was no documentation on either MAR that the resident had refused his [MEDICATION NAME] medications. She said to her knowledge, the resident had not refused his pain medications. -She reviewed and acknowledged the nursing notes 1/31/17 at 17:48 (5:48 p.m.) to 2/3/17 at 11:26 a.m. that noted the nursing staff were waiting on the [MEDICATION NAME] medication to be delivered from the pharmacy. She said the nursing staff needed to request a hard copy (paper) for a prescription for the [MEDICATION NAME] medication from the resident's physician and send it to the pharmacy. The pharmacy would not deliver the [MEDICATION NAME] medication without a prescription. She said the facility had this medication ([MEDICATION NAME]) in the emergency kit (Ekit). She said the nursing staff did not use any of the [MEDICATION NAME] medication from the Ekit for this resident. She said it was her expectation the nursing staff should have used the [MEDICATION NAME] medication in the Ekit for this resident. e. On 2/9/17 at 12:44 p.m., the NHA said it was her expectation staff follow facility polices (see above). B. Resident #2 1. Resident Status Resident #2, age 74, admitted [DATE] and readmitted [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 11/25/16 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview score of 15 out of 15. The resident was on a scheduled pain medication regimen and received PRN (as needed) pain medications. The resident did not receive non-medication interventions for pain. Staff reported the resident made vocal complaints of pain three or four days of the seven-day assessment period. According to the physician's orders [REDACTED]. The resident also had orders to received [MEDICATION NAME] 50mg; one tablet by mouth in the evening for low back pain. 2. Resident Interview Resident #2 was interviewed on 2/8/17 at 4:58 p.m. She said she had chronic pain in her lower back. She said for pain control, she used a pain medication patch that was changed every three days ([MEDICATION NAME]) and pain pills ([MEDICATION NAME]). She said the facility would often run out of the patch and the change would be delayed. She said the facility also frequently ran out of her [MEDICATION NAME]. She said when this happened, she would get extremely uncomfortable and would be offered [MEDICATION NAME] (Tylenol) as an alternative pain medication. 3. Record Review Record review confirmed resident #2's pain medication was not always available for administration and her pain was not always addressed. a. [MEDICATION NAME] During the resident's interview on 2/8/17 at 4:58 p.m., the resident was observed wearing a patch dated 2/4/17 which meant the patch had been applied four days earlier and, per the physician's orders [REDACTED]. According to the February electronic medication administration record (eMAR), the resident did not receive a patch as ordered on [DATE]. The nurse's note dated 2/7/17 at 5:03 p.m. documented, Pharmacy notified of need (for patch). Not available at this time at facility. b. [MEDICATION NAME] A nurse's note dated 1/14/17 at 7:27 p.m. documented [MEDICATION NAME] was not given and was on order. Give Tylenol. According to the eMAR, [MEDICATION NAME] was not administered on 1/14/17. Another nurse's note dated 1/15/17 at 8:14 p.m. documented [MEDICATION NAME] remained unavailable. According to the eMAR, [MEDICATION NAME] was administered on 1/15/17 at 8:58 p.m. c. Other record review Review of the resident's comprehensive care plan revealed no care plan describing or addressing the resident's pain. However, the electronic treatment administration record (eTAR) revealed the resident was assessed for pain three times a day. According to the eTAR, the resident reported pain daily, including the days the pain medications were unavailable. Further review of the resident's record revealed no documentation the physician was notified the resident's pain medications were not administered as ordered on the above dates. 3. Staff Interviews Licensed practical nurse (LPN) #7 was interviewed on 2/8/17 at 1:54 p.m. She said medications were reordered through the electronic medical record system, and the pharmacy made deliveries every evening. She said nursing staff often would spend a lot of time on the phone with the pharmacy to sort out refill orders because they had difficulty getting the medications they ordered. LPN #5 was interviewed on 2/8/17 at 1:57 p.m. She said that they had difficulty receiving narcotic medications (such as [MEDICATION NAME] and [MEDICATION NAME]) from the pharmacy frequently, but nurses had an emergency kit available to pull pain medications from if the resident was out of pain medication. She said [MEDICATION NAME] 50mg tablets were in the kit but [MEDICATION NAME] 12mcg patches were not. Registered nurse (RN) #4 was interviewed on 2/8/17 at 3:05 p.m. He confirmed the resident was due for a new [MEDICATION NAME] the previous day, but it had not yet come in from the pharmacy. He said the patch would be applied as soon as it was delivered. The DON was interviewed on 2/9/17 at 11:22 a.m. She said resident #2's patches ran out and they did not have the required physical copy of the prescription for the refill to be authorized. She said the nurses should start the reordering process early, when there is still some of the medication left, to avoid that issue. II. Management of Other Resident Conditions A. Resident #5 - Skin 1. Resident Status Resident #5, age 89, admitted on [DATE]. According to the face sheet, [DIAGNOSES REDACTED]. According to the 12/16/16 minimum data set (MDS) assessment, the resident had cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required extensive one-person physical assistance for activities of daily living (ADLs) and had no skin problems. 2. Resident interview Resident #5 was interviewed on 2/8/17 at 9:14 a.m. She said she had a sore on her bottom and that it hurt when she moved her legs. She described it as feeling like a scab splitting apart when she moved, and she said it felt like she was sitting on something when she was not moving. She said she was supposed to get a pad and cream on it every day, but said that did not always happen. She said she had a wound on her heel at one point, but it had healed. 3. Record Review The care plan dated 6/15/16 documented the resident had a potential for skin impairments due to limited mobility, and a pressure injury to her left heel. Care planned interventions included: Notify MD (medical doctor) of changes in wound or emerging wounds. Observe wound healing. Provide wound care / preventative skin care per order. Skin checks weekly per facility protocol, document findings. Turn and reposition frequently to decrease pressure. The care plan did not include information about current skin impairments. A nurse practitioner (NP)'s progress note dated 9/27/16 documented, Skin: Bilateral lower buttock is red (approx. 4x2). Skin is intact. No rash apparent. Assessment and plan: 1) Pressure ulcer of unspecified buttock, unspecified stage: pressure related sore. Stage 1. Continue to clean, apply [MEDICATION NAME]. Fungal rash from last week is almost cleared. Foam dressing to area of pressure. Encourage (resident #5) to lay side to side when in bed and to not be in her chair all day. She will be seen by (facility)'s wound care team with (wound care physician). There were no weekly skin assessments documented on 1/29/17 or 2/5/17. The most recent skin assessment was dated 1/22/17. It read the resident had no pressure injury to her left heel but an existing pressure injury to the sacrum was present. This assessment, as with previous assessments, included no wound descriptions, staging, or measurements were included in the assessment. 4. Observations Resident #5's skin condition was observed with LPN #5 and the ADON on 2/8/17 at 10:12 a.m. The nurses assisted the resident to a standing position and pulled down her pants, revealing wounds to her bilateral buttocks. The left buttock appeared to be red, flaky moisture-associated skin damage without any open areas. The right buttock appeared to have a partial-thickness circular wound approximately dime sized, without signs of necrosis or infection. There was no foam dressing in place to the resident's buttocks, as per physician's orders [REDACTED]. 5. Staff Interviews The ADON was interviewed on 2/8/17 at 8:47 a.m. She said she served as the facility's wound care nurse. She said resident #5 did not have any current wounds, and that the wound on the resident's sacrum had healed a long time ago. She said the existing pressure ulcer documented on the 1/22/17 skin assessment was incorrect documentation, and the resident had a preventative dressing on her buttocks. She said the nurse practitioner (NP) had evaluated the resident and determined she had a chronic red area that was not pressure related but would never fully heal. She said the resident was not followed by the wound care team. LPN #5 was interviewed on 2/8/17 at 10:13 a.m. She said nurses should check every resident's skin weekly to look for open areas. She said she was unaware of the current wounds on the resident's bilateral buttocks. The ADON was interviewed again on 2/9/17 at 11:10 a.m. She said the NP had evaluated the resident the previous afternoon, and had diagnosed the resident with a chronic skin condition and classified the open area to the right buttock as a [DIAGNOSES REDACTED] blister. There was a new order for the resident to see a dermatologist to confirm the diagnosis. C. Resident #8 - Urinary tract infection 1. Resident Status Resident #8 was admitted [DATE]. According to the 2/17 computerized physician orders, [DIAGNOSES REDACTED]. According to the 1/8/17 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance for bed mobility, dressing and toileting and total assistance for transfers and bathing. The resident's care plan did not include a current or discontinued care plan for a urinary tract infection, a [DIAGNOSES REDACTED]. 2. Record Review A nurse practitioner note, dated 11/21/16, documented He (resident) c/o (complains of) burning and frequency of urination. He believes he has a UTI (urinary tract infection) and 1. UTI (urinary tract infection) - Dysuria - UA with C&S (culture and sensitivity) as necessary. The 11/22/16 telephone order documented Please obtain UA results done yesterday. The 11/25/16 telephone order documented UA C&S (culture and sensitivity) repeat now if unable to find last week's results . The 11/29/16 telephone order documented Encourage PO (by mouth) fluids, Bactrim DS PO Q12 (every twelve hours) x 5 days (for five days) for UTI (urinary tract infection) . The lab results of the UA, collected 11/25/16 and received 11/26/16, revealed the resident had an abnormal result for [MEDICATION NAME] Urine, Red Blood Cells Urine 3-5, Bacteria Urine 1+ and Calcium Oxalate Crystals 5-10. The 11/16 medication administration record (MAR) documented the resident received Bactrim DS Tablet 800 - 160 mg (miligrams) once on 11/29/16 and twice on 11/30/16. The 12/16 medication administration record (MAR) documented the resident received Bactrim DS Tablet 800 - 160 mg twice on 12/1/16, twice on 12/2/16, twice on 12/3/16 and once on 12/4/16. 3. Staff Interviews On 2/13/17 at approximately 1:00 p.m. NP #1 was interviewed. She said NP #2 wrote in her note a request for a UA to be obtained. The NP #1 agreed from the initial note on 11/21/16 the resident did not receive the ordered antibiotic until eight days later and the lab did not collect the urine for the ordered UA until 11/25/16. NP #1 agreed the antibiotic did not begin until 11/29/16. On 2/13/17 at approximately 1:30 p.m. the DON was interviewed. She agreed the nurse practitioner note, dated 11/21/16, requested a UA to be obtained. The DON confirmed the lab did not collect the urine for the ordered UA until 11/25/16, after the nurse practitioner requested a second UA. She confirmed the resident did not receive the ordered antibiotic until eight days after the initial request for a UA. On 2/14/17 at 12:40 p.m. the director of nursing (DON) confirmed when the nurse practitioner (NP) #2 wrote in the 11/21/16 note UA with C&S this would be considered an order for [REDACTED].

Based on observations, record review and interviews the facility failed to ensure one (#1) of one sampled resident was free from any physical restraints. Specifically, the facility failed to: -Assess and care plan restraint use on an ongoing and timely basis; -Follow physician orders [REDACTED]. -Obtaining a current physical restraint consent; -Obtain an order, develop a care plan and timely evaluate for the wheelchair safety saddle; -Code physical restraints in the minimum data set (MDS) correctly; -Ensure the facility used a lap tray the resident could remove easily, if physically able, which prevented the resident from rising; and -Engage in a systematic and gradual process toward reducing the lap tray and the wheelchair safety saddle restraints. Specifically, the facility caused the resident harm as evidenced by the resident's behavior of repeated verbalization of chanting sounds and the inability to sit still as evidenced by pulling on the lap tray, banging on the lap tray with hands and observed anxiousness, agitation and angry facial expressions which caused psychomotor and verbal agitation. A. Facility Policy and Procedure The restraint management policy and procedure, revised 8/12 and provided by the social services assistant (SSA) on 9/9/16 at approximately 9:30 p.m. revealed, in pertinent part: -Alternative interventions must be attempted and fully documented in the nursing notes, in the care plan and on the RCS Assignment Sheet/Care Kardex. -The resident, family member or legal representative will be included in the decision process. -A Physical Restraint Consent form is completed, signed and placed in the clinical record. Consents much be updated at least annually, or with any changes to the device being used. -Restraints are applied using the manufacturer's instructions. When securing restraints, a quick release knot is used. -During the time a restraint is in place, the restraint is periodically removed and the resident is assisted with change of position, range of motion and/or stretching. Restraints should always be removed during supervised mealtimes and supervised activities. -The At-Risk Review Meeting is completed at least quarterly by the IDT (interdisciplinary team) to determine continued need for the retrain device and to continually assess for opportunities to reduce or eliminate the restraint. B. Resident Status Resident #1, age 73, was admitted to the facility on [DATE]. According the computerized physician's orders [REDACTED]. The 6/10/16 minimum data set (MDS) assessment revealed the resident had unclear speech, rarely/never made self understood, and rarely/never was able to understand others. He had short and long term memory problems, had no memory/recall ability and had severally impaired cognitive skills for daily decision making. The resident had signs of [MEDICAL CONDITION] which included continuous inattention, disorganized thinking and psychomotor [MEDICAL CONDITION]. The MDS revealed the mood assessment, completed by staff, that the resident had little energy, difficulty concentrating on things, moved slowly and was short tempered. The resident exhibited other behavioral symptoms not directed toward others and rejection of care occurred daily. The resident required two-person physical assistance with all activities of daily living (ADL). The resident received both, an antipsychotic and an antianxiety medication seven of the last seven days during the review period. The assessment revealed the resident had a limb restraint which was used less than daily and a wheelchair which prevented rising daily. C. Observations/Staff Interviews - 9/8/16 On 9/8/16 at 4:59 p.m. certified nurse aide (CNA) #1 and CNA #3 were observed providing the resident cares. The CNAs assisted the resident in the sit-to-stand mechanical lift. The resident was agitated and began shaking the lift and grabbing at the aides. He held onto their hands while they continued to provide cares. Once he was standing, the back of his pants were noted to be soaked from his waist to his knees, and a strong urine odor filled the room. CNA #1 said his pants were wet with urine. The CNAs wiped the resident's backside and applied a clean brief. They set him in the chair so they could change his pants, and stood him a second time to pull his pants up. While providing cares, the resident cursed and muttered at the CNAs the entire time and attempted to hit the CNAs multiple times. CNA #1 said this was the first time they had changed him on their shift which started at 2:00 p.m. She said she was unsure what time the day shift CNAs had gotten the resident up. Both CNAs were unsure how long he had been up in his chair. The resident was noted to be grimacing throughout the interaction. He also had visible bruises on bilateral hands. The tray was replaced at the conclusion of the cares and it was noted that the resident's feet were dangling, approximately four inches above the ground. He had slipper socks on and CNA #1 said that footrests are not used with his wheelchair. She said his feet were allowed to dangle when he was up. She said that he used to lay down in the afternoons, but the past couple of weeks he had been too agitated to lay in bed because he attempts to get out of bed, therefore they leave him up in his chair. On 9/8/16 at 5:48 p.m. the resident was observed seated in the dining room with his lap tray secured to his wheelchair. CNA #1 sat down and began to feed him his pureed dinner. She said the tray stays in place throughout meals. She said if they remove it, he doesn't stay put. She said they have attempted several times to remove it during meals. Instead, they check on him frequently, offer snacks and try to leave his door open. E. Observations - 9/9/16 On 9/9/16 at 5:08 p.m. the resident was observed sitting in his room with the lights out, the blind partially open and the door open. The resident's room was located next to the nurses' station and across the hall from the dining room. The resident did not have a roommate. The resident was sitting in his wheelchair with a lap tray secured to his wheelchair. The lap tray was attached with a buckle on one side and a broken strap twisted through the wheelchair and lap try and secured with a knot on the outside of the wheelchair. The resident was sitting in a wheelchair which was slightly reclined. The resident was sitting on a wheelchair safety saddle (wedged contour pommel cushion), which was covered by a bath blanket. The wheelchair safety saddle was 4 ½ tall in the front and was tapered towards the back which was 1 ½ tall. The resident was wearing nonskid socks with the rubber non-skid strips on the top of his feet. His feet were dangling above the floor approximately four inches. The resident was reaching across his lap tray and hanging on to the front of the tray with both hands attempting to pull on it repeatedly. The resident's facial expressions appeared anxious, nervous, agitated and angry. The resident made loud and unrecognizable chanting sounds. On 9/9/16 at 5:23 p.m. the resident was continuously observed until 9:17 p.m. The following observations were made: -The resident was pushed into the dining room and placed at the table in his wheelchair. His meal was placed in front of him on the table. The lap tray remained on during the entire meal. The resident ate all of his dinner and drank all of his beverages that were offered, with assistance from the CNA. -The resident remained at the dining room table until 5:59 p.m. when he was pushed into his room. The resident began banging his lap tray and hanging on to the front of the tray with both hands attempting to pull on it repeatedly and wiggle his legs, which did not touch the ground. The resident's facial expressions appeared anxious, nervous, agitated and angry. The resident made loud and unrecognizable chanting. - At 6:01 p.m. the resident's hand mitts were placed on his hands and his lap tray was removed. The resident's facial expressions appeared anxious and angry. The resident made loud and unrecognizable chanting sounds. The resident was striking out at both CNAs who were assisting him. The sling was placed around the resident's body and secured. The resident's hands were loosely placed on the sit-to-stand lift, although the resident was unable to hold it and he was lifted out of the unlocked wheelchair. The resident's brief was removed and a new brief was placed on the resident. The resident's pants were pulled up and the resident was lowered into his wheelchair at 6:06 p.m. The hand mitts were removed and the lap tray was immediately secured to the wheelchair with a buckle on one side and a strap that was twisted through the lap tray and the wheelchair and tied in a knot. The CNAs left the room and the resident remained in his room near the bed, partially facing the door. -From 5:59 p.m. until 6:49 p.m. the resident remained in his room. He would periodically bang on his lap tray, call out, hang on to the front of his lap tray and pull on it repeatedly and wiggle his legs. No staff entered the room. -At 6:49 p.m. the assistant director of nursing (ADON) went into the resident's room. She had two containers of flavored gelatin, each contained approximately two tablespoons of gelatin. She sat down with the resident and fed him the gelatin, gave him one glass of cranberry juice and talked with him. The resident was calm while being fed and spoken with by the ADON. Afterwards the resident became agitated and began calling out. At 6:52 p.m. the ADON began rubbing the resident's back and talking to him. The resident stopped calling out and banging his lap tray. The ADON left the room at 6:53 p.m. The lap tray was not removed at any time during this observation. -From 6:53 p.m. until 8:47 p.m. the resident remained in his room with the light on and the door open. The resident would intermittently become agitated and call out, bang his lap tray, hang on to the front of the tray with both hands attempting to pull on it repeatedly and wiggle his legs. The resident's facial expressions appeared anxious, nervous, agitated and angry. The resident made loud and unrecognizable chanting. When the resident was not calling out, pulling or banging on his tray his head was bent and facing downward. The resident appeared as if he was sleeping. During this time staff did not enter the resident's room. The resident's position was not changed by staff and the lap tray remained secure since 6:06 p.m. -At 8:47 p.m. CNA #1 entered the room with a small container of pudding and a glass of cranberry juice and removed the resident's lap tray. The resident ate and drank both the pudding and the cranberry juice. The resident appeared calm, did not strike out and did not make chanting sounds. The lap tray was secured on the resident's wheelchair at 8:52 p.m. -At 9:04 p.m. CNA #1 and CNA #2 entered the room. The resident's face appeared agitated and tired. The CNAs removed the resident's lap tray. The resident was grabbing at the tray, attempting to strike out at both CNAs and making unidentifiable chanting sounds. The CNAs did not use hand mitts while providing cares. The CNAs used the sit-to-stand mechanical lift to change his brief and prepare him for bed. The resident was then transferred to his bed. C. Record Review a. Medication Review Report The 9/16 medication review report revealed the resident had the following order: -Lap tray every shift for assistive device, lap tray to wheelchair, remove for meals, activities of daily living (ADLs) and supervised activities, start date 4/15/15. There was no order for the wheelchair safety saddle. b. Treatment Administration Record (TAR) The 9/16 TAR documented lap tray every shift for assistive device, lap tray to wheelchair, remove for meals, activities of daily living (ADLs) and supervised activities, start date 4/15/15. The TAR revealed on 9/8/16 the lap tray was removed during the evening shift to include the evening meal. The observation on 9/8/16 (see above) revealed the tray was not removed during the evening meal. The interview on 9/8/16 (see below) with CNA #1 and registered nurse (RN) #1 revealed the lap tray was never removed during the evening meal. c. Physical Restraint Consent The physical restrain consent dated 1/22/15 documented a verbal consent was obtained but did not document who provided the verbal consent. The form documented the restraint type, frequency was table tray in w/c (wheelchair). The specific target behaviors included uncontrollable rocking in chair and leaning forward in w/c causing res(ident) to fall out of w/c. The medical symptom was dementia with behaviors. The consent was not signed by the physician. The social services assistant (SSA) confirmed this consent was the only consent in the resident's medical record. d. Care Plans The physical restraint care plan initiated and revised on 5/24/16 and on 9/9/16 revealed the resident used a lap tray restraint related to injury. The interventions included: ensure resident was positioned correctly with proper body alignment while restrained, evaluate/record continuing risks/benefits of restrain, alternatives to restrain, need for ongoing use and reason for restraint use. Following the survey the nursing home administrator (NHA) provided a revised version of the care plan. The revised version, dated 9/12/16, included additional interventions: monitor for reduction/elimination via IDT reviews while attempting and maximizing safety, reposition every two hours and ensure the resident is positioned correctly and release lap tray with toileting/incontinent and all other ADL care, with meals and supervised activities. e. Progress Notes The social services note, written by the social services director on 9/6/16 revealed a care conference was held. The family did not attend. The note documented therapy has attempted to d/c (discontinue) the lap tray but have been unsuccessful. The nurses' notes dated 8/29/16, 8/26/16, 8/24/16, 8/20/16 and 8/18/16 documented the resident was agitated and slapped lap tray. A review of the progress notes from 7/1/16 through 9/9/16 revealed there were no other notes regarding the lap tray or the wheelchair safety saddle. f. Kardex The Kardex documented for safety to apply lap tray restraint for safety, release with toileting/incontinent and all other ADL care, with meals and supervised activities. g. Occupational Therapy The occupational therapy (OT) discharge summary, dated 6/28/16 documented OT does not recommend taking off lap tray. Staff Interviews The registered nurse (RN) #1 was interviewed on 9/8/16 at 5:20 p.m. She said the resident takes routine pain medications. When asked how she differentiates between pain and behaviors, she said Honestly, I think he's thirsty. She said that he often becomes more calm at dinner time when being fed and given drinks. She said that he typically will drink three full glasses during dinner and will eat all of his food. She was unsure if the resident received snacks. RN #1 was interviewed on 9/8/16 at 6:20 p.m. She said staff do not remove the lap tray during meals, so technically we are not following the physician's orders [REDACTED]. She said we do not remove it because the resident strikes out and he was generally calm during meals. She said he periodically was taken to activities. She said he will have a visitor who will visit and sometimes take him outside. She said the lap tray remains on during those visits. RN #1 was interviewed on 9/9/16 at 5:48 p.m. She said the lap tray was always removed during cares but never at meals. She confirmed the order for the lap tray documented the lap tray should be removed during all meals. She confirmed the order was not being followed. The SSA was interviewed on 9/9/16 at 5:23 p.m. She reported she generally worked late and was the assigned social worker for the secure unit. She said she liked to work in the evening to watch the residents. She said she could learn a lot about each resident because they were very different right after dinner and in the evening. The SSA was interviewed on 9/9/16 at 7:19 p.m. She reported she was not specifically involved in the decision about a resident having a restraint. She said during the morning meeting restraints would be discussed but that was the only time she was involved in the conversation. She said she remembered staff talking about the position of the chair approximately two weeks ago during the morning meeting. She said she did not recall any conversation regarding the wheelchair safety saddle. She said the director of nursing (DON) managed the restraints. Certified nurse aide (CNA) #2 was interviewed on 9/9/16 at 5:59 p.m. He reported he would only remove the lap tray when it was safe without it. He said in the past they had removed the tray at dinner time but the resident started hitting people. He said they will use hand mitts during cares to avoid skin tears. He confirmed the lap tray buckle was broken on the right side and needed to be tied onto the wheelchair. CNA #1 was interviewed on 9/9/16 at 6:01 p.m. She said she had worked on the secure unit for approximately two years. She reported she had provided cares for the resident last at 3:30 p.m. She confirmed the last time the lap tray had been removed was when she provided cares at 3:30 p.m. She reported she had not received any special training for working with the resident regarding his behaviors and/or lap tray. The CNA #1 was interviewed on 9/9/16 at 8:47 p.m. she said she would try and stick her head in occasionally and say hi during her shift. She said lately the lap tray has been staying on but she may start to do something different. The DOR was interviewed on 9/9/16 at 8:16 p.m. She said another OT in her department had completed multiple assessments for the resident for his lap tray. She said certain days the resident was fine and other days he was agitated and thrusting out of his chair. She said she would never consider the wheelchair safety saddle a restraint and did not know she needed an order for [REDACTED]. She said the therapist would complete a trial again and assess the lap tray. She agreed the orders for the lap tray should be followed. The ADON was interviewed on 9/9/16 at 9:17 p.m. She said the resident's lap tray should be removed during cares, meal service and 1:1. She said she had never received any formal training related to the residents lap tray or managing his behaviors. She said she was not aware she should remove the lap tray when providing a snack. She said the resident was more agitated than usual during this evening, therefore she did not want to go into the resident's room too much to see if she could calm or redirect him. She said, during the evening, CNA #2 had offered to go into room and turn on music but she had directed him not to because the resident already seemed agitated. She said she did not want to increase his agitation. She said she was probably not very helpful during the interview because she does not spend much time in the secure unit. The DON was interviewed on 9/9/16 at 7:01 p.m. She said she had started in her position in 3/16. She said when she started there were five restraints in the building and all but one has been eliminated. She said they have tried for five months to get rid of the resident's lap tray but they have been unsuccessful. She said the lap tray was removed for meals and ADLs. When the DON was told about observations where the lap tray was not removed during meals she said it probably should be removed. She said she thought the lap tray was a comfort to the resident. She said we will check the MARS and make observations to ensure the care plan is being followed. The DON and NHA were interviewed on 9/9/16 at 10:04 p.m. They both agreed that orders should be followed and the lap tray should be removed based on physician's orders [REDACTED].

Based on record review, resident interview and staff interview, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical well-being for five (#115, #73, #147, #128 and #22) of 43 sample residents. Specifically: -The facility failed to manage resident #115 high blood sugars according to physician orders, which resulted in two hospitalization s for uncontrolled high blood sugars. -The facility failed to adequately assess pain and monitor the effectiveness of pain medications for resident #115 and #73. -The facility failed to notify the physician of a change of condition for resident #147 and comprehensively assess resident #128 after a fall. -The facility failed to ensure compromised skin on the face of resident #22 was assessed and treated. The findings include: 1. Resident #115 Resident #115, age 57, originally was admitted to the facility on [DATE] with diagnoses, according to the face sheet, of type I diabetes mellitus, hypertension, [MEDICAL CONDITION], joint pain, cataract, chronic ischemic [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. a. Record Review The 1/15/13 re-admission orders [REDACTED] -2 units (u) for blood sugars (BS) of 151 to 200; -4 u for BS of 201 to 250; -6 u for BS of 251 to 300; -8 u for BS of 301 to 350; and -10 u for BS of 351 to 400. The 8/2/12 diabetic care plan, updated 12/16/12, documented the resident was at risk for hypo- and hyper-glycemia and refused blood sugar checks and medications at times. The approaches included: observe for signs and symptoms of hypo- or hyper-glycemia, perform blood sugar checks as ordered, administer sliding scale insulin as ordered, provide medications as ordered, observe for dietary compliance, educate the resident on the risks of hypo- or hyper-glycemia, and inform the resident of medication changes. (1) Failure to follow orders 1/15/13 - 1/20/13 Cross-reference F333: Significant Medication Errors - Review of the sliding scale insulin sheets (SSI), medication administration records (MAR), and orders revealed the facility failed to ensure sliding scale insulin (SSI) was administered per the physician's order eight times from 1/15/13 to 1/20/13. (2) Failure to follow orders 1/21/13 - 2/10/13 Review of the sliding SSI, MAR, telephone orders (TO), nurses notes, and hospital transfer forms revealed: On 1/21/13, 7:00 p.m., the resident's BS was 33. A 1/21/13, 7:00 p.m., physician's telephone order (TO) documented an order to administer one milligram (mg) of [MEDICATION NAME], re-check the BS at 7:30 a.m. the next day, discontinue the SSI, and check BS four times daily and as needed. At 7:30 p.m., the BS was 83. On 1/22/13 before breakfast, the resident's BS was 413. Two units of SSI [MEDICATION NAME] were given. A 1/22/13, 7:30 a.m. TO documented an order to administer two units of [MEDICATION NAME]. A 1/22/13 TO documented an order to discontinue BS checks four times daily and start BS checks three times daily. On 1/23/13 at 7:00 a.m., the resident's BS was 408. Three units of SSI [MEDICATION NAME] were given. A 1/23/13 TO documented an order to administer three units of [MEDICATION NAME]. On 1/26/13 at bedtime, the resident's BS was 392. There was no documentation of any action taken or a BS re-check. On 1/27/13 before breakfast, the resident's BS was "HI." Two units of SSI (type of insulin not identified) were given. The form documented the physician was notified, though there was no evidence of the physician order to administer two units of insulin in the record. On 1/27/13 before lunch, the BS was "HI." The resident was transferred to the hospital. A 1/27/13, 12:00 p.m. TO documented an order to transfer the resident to the hospital for a "HI" BS. The 1/30/13 re-admission physician orders documented an order for [REDACTED]. The hospital discharge medication orders documented an order for [REDACTED]. This order was not transcribed to the re-admission physician orders at the facility. On 1/30/13 at 8:30 p.m., the resident's BS was "HI." He was not given any SSI as ordered on the re-admission orders HI." The 1/31/13 nurse's note documented the resident's BS at 12:00 a.m. was higher than 600. Five units of [MEDICATION NAME] were given "per resident request." There was no physician order for [REDACTED]. There was no documented notification to the physician of the variance in medication administration. There was no evidence the resident's BS was re-checked after the administration of the five units of [MEDICATION NAME]. The 1/31/13, 7:00 a.m. nurse's note documented the physician was called regarding the 12:00 a.m. BS and a new order was received. A 1/31/13 TO documented an order to administer four units of [MEDICATION NAME] and discontinue the [MEDICATION NAME]. On 1/31/13 at 4:45 p.m., the resident's BS was 593. A 1/31/13 TO documented an order to give three units of [MEDICATION NAME] and send the resident to the emergency room for uncontrolled BS. The physician was called. A 1/31/13 transfer form documented the resident was sent to the hospital with high blood sugars. The 2/6/13 re-admission physician orders documented the SSI order: for a blood sugar of 350 to 400, give two units of regular insulin three times daily. The February 2013 SSI record documented: -On 2/7/13 at 4:00 p.m., the BS was 456. Two units of SSI were given. Though the form documented "yes" under physician notification, there was no evidence in the medical record the physician was notified or an order was received to administer two units of insulin. -On 2/10/13 at 4:00 p.m., the BS was 375. No SSI was administered. b. Staff Interview On 2/12/13 at 5:30 p.m., the director of nursing (DON) stated the resident was often non-compliant with physician orders and requested certain amounts of insulin or refused insulin at times. The DON stated she would expect the resident's care plan to document this behavior and the staff to notify the physician of the resident's non-compliance and educate the resident on the risks of non-compliance. The DON stated the staff would be provided with education on following physician orders for SSI administration. The DON stated the resident was "difficult" and would be discharged home as soon as possible. On 2/12/13 at 5:45 p.m., the DON stated the SSI was discontinued on 1/31/13. She did not explain why the re-admission order for SSI was not transcribed on 1/30/13 and the SSI was not administered on 1/30/13. 2. Resident #73 Resident #73 was admitted to facility on 11/16/12 with the diagnoses of [MEDICAL CONDITIONS] reflux, asthma, chronic diastolic heart failure, chronic pain, [MEDICAL CONDITION], personality disorder, diabetes mellitus, [MEDICAL CONDITION], and hypertension. The 11/23/12 admission minimum data set (MDS) assessment documented the resident was independent with memory and cognition. She exhibited [MEDICAL CONDITION] and rejection of care. The resident was not on a scheduled pain medication regimen, but received PRN pain medications. She had pain almost constantly, at an 8 on a scale from 1 to 10, that made it hard for her to sleep at night. a. Resident Interview On 2/6/13 at 2:25 p.m., the resident stated she had back pain. She stated she received [MEDICATION NAME] every six hours, but by the time she was due for another dose, her pain was overwhelming. She stated she had not seen a doctor since November 2012. b. Record Review The 2/13 CPOs documented the following pain control orders: -11/16/12: [MEDICATION NAME], 300 mg three times daily for pain; -1/6/12: [MEDICATION NAME], 5/500 mg, one to two tabs every four to six hours PRN (no [DIAGNOSES REDACTED]. -11/16/12: [MEDICATION NAME], 600 mg every eight hours PRN; -12/3/12: [MEDICATION NAME], one patch every day as needed for pain. The 11/16/12 quarterly pain evaluation documented the resident had lower back pain and received scheduled and PRN pain medication. She had frequent pain over the last five days and had limited her day-to-day activities because of the pain. Her present pain was rated a 6 out of 10. A 12/12/12 care plan documented the resident had a potential for pain and chronic back pain. The approaches included: provide non-pharmacological interventions such as music, relaxation, and counseling; administer pain medications as ordered; monitor for signs and symptoms of pain every shift, notify the physician if interventions are not effective, and medicate the resident prior to treatment. On 1/7/13, the order for [MEDICATION NAME], 5/325 mg, every 8 hours was discontinued and [MEDICATION NAME] 5/500 mg, one to two tablets every four to six hours was ordered. The new dosage of pain medication was two to three times higher over a 24-hour period than previous medication order. The 1/13 MAR documented: -The [MEDICATION NAME] was not administered at all during the month. -The [MEDICATION NAME] was administered on 1/1, 1/4, 1/7, 1/9, 1/15, 1/22, 1/26 and 1/29/13. The reason for administration and effectiveness of the medication were not documented. -The [MEDICATION NAME] was administered: -Three times on 1/8/13, -Once on 1/9/13, -Twice on 1/10/13, -Once on 1/11/13, -Once on 1/12/13, -Once on 1/13/13, -Twice on 1/14/13, -Once on 1/15/13, -Once on 1/19/13, and -Once on 1/20/13. The MAR did not specify whether one or two tabs were given, what the resident's pain level was prior to administration, and the effectiveness of the medication. The 1/13 PRN pain medication record documented the [MEDICATION NAME] was given: -Once on 1/8/13 for a pain level of 8. The pain was reduced to a 2. -Once on 1/11/13 for a pain level of 8. The pain was reduced to a 2. -Once on 1/12/13 for a pain level of 8. The pain was reduced to a 2. -Once on 1/14/13 for a pain level of 8. The pain was reduced to a 3. -Once on 1/15/13 for a pain level of 8. The pain was reduced to a 3. -Twice on 1/19/13 for pain levels of 8 at 4:00 a.m. and 5 at 11:00 p.m. The pain was reduced to a 3 and 2, respectively. -Once on 1/20/13 for a pain level of 7. The pain was reduced to a 1. -Twice on 1/24/13 for pain levels of 4 at 12:00 a.m. and 3 at 10:45 p.m. The pain was reduced to a 0 both times. -Once on 1/27/13 for a pain level of 10. The pain was reduced to a 2. -Once on 1/31/13 for a pain level of 8. The pain was reduced to a 3. The record did not specify whether one or two tabs were given. Though the above 12 administrations documented the reason for and effectiveness of the medication, there was no such documentation for the other days listed on the MAR (twice on 1/8/13, 1/9/13, twice on 1/10/13, 1/13/13 and once on 1/14/13). The 1/13 MAR documented the resident had pain rated as zero (0) on all but three shifts, with seven shifts having no documentation. The 2/13 MAR documented: -The [MEDICATION NAME] was not administered at all during the month. -The [MEDICATION NAME] was given on 2/5, 2/6, and 2/7/13. The reason for administration and effectiveness of the medication was not documented. -The [MEDICATION NAME] was given on 2/3, 2/4, 2/5, 2/6, 2/7, and 2/8/13, one time each day. There was no documentation of the pain level prior to administration, the effectiveness of the medication, and whether one or two tabs were given. The 2/13 PRN pain medication record documented the [MEDICATION NAME] was given: -On 2/4/13 for a pain level of 6. The pain was reduced to a 1. -Twice on 2/7/13 for a pain level of 8 at 6:00 a.m. and a pain level of 6 at 11:00 p.m. The pain was reduced to a 2 and a 1, respectively. -On 2/9/13 for a pain level of 8. The pain was reduced to a 2. Though the above four administrations documented the reason for and effectiveness of the medication, there was no such documentation for the other days listed on the MAR (2/3/13, 2/5/13, 2/6/13 and 2/8/13). The 2/13 MAR documented the resident had pain rated as zero (0) on all shifts. review of the resident's medical record revealed [REDACTED]. Though there were four to six opportunities daily to administer the PRN [MEDICATION NAME], it was not given as frequently according to the MAR and PRN pain medication record. 3. Resident #115 See diagnoses above. a. Record Review The 10/21/12 quarterly MDS assessment documented the resident was not on scheduled pain medicine and did not receive PRN pain medications. He was assessed as having no pain. However, the 8/2/12 Care Plan, reviewed 10/21/12, documented the resident had actual pain related to chronic disease. The approaches included: provide non-pharmacological interventions, administer [MEDICATION NAME] as ordered, implement the pain management flow sheet, monitor for signs and symptoms of pain, and notify physician of ineffective pain interventions. The 2/6/13 re-admission physician orders noted an order for [REDACTED]. -Review of the PRN Pain medication administration record documented that one [MEDICATION NAME] had been administered on 1/7/13. There was no documentation of the reason for pain medication or results of pain medication. -Review of the Controlled substance log for the [MEDICATION NAME] revealed [MEDICATION NAME] had been signed out for the resident on 2/7/13, three times, 2/8/13, two times. Upon review of the record, the five administrations of [MEDICATION NAME] were not reflected on the 2/13 MAR or PRN Pain flow sheet. There was no documentation of the reason for pain medication or results of pain medication. b. Staff Interview On 2/12/13 at 3:45 p.m., the DON stated that she would expect pain levels to be monitored and documented before and after PRN pain medicine was administered. 4. Resident #128 Resident #128, a [AGE] year old male was admitted to the facility on [DATE]. According to the facility admission record, his diagnoses included acute [MEDICAL CONDITION], mitral/aortic valve insufficiency, cardiac [MEDICAL CONDITION], gout, [MEDICAL CONDITION], aortic atresia stenosis, chronic ischemic heart disorder, hypertension, [MEDICAL CONDITION] of liver and pneumonia. a. Resident Status According to the fall care plan, dated 11/9/12, the resident was at risk for falls related to recent admission, utilization of assistive devices, narcotic use, [MEDICAL CONDITION] use, [MEDICAL CONDITION] and multiple heart conditions. The approaches included: -Encourage resident to ask for assistance as needed. -Interdisciplinary referral as needed: Physical therapy, Occupational therapy, Restorative nursing, and Social services. -Orient resident to room/environment. -Provide assistive devices as indicated and accepted. Cane, w/c (wheelchair) FWW (four wheel walker)-will use devices to bathroom. -Bed alarm. -Room change closer to nurses' station. -Place frequently used items within reach. Review of fall reports revealed falls on 11/19/12 (lost balance turning around in bathroom) and 11/27/12 (tangled in oxygen tubing in resident's room). The falls were reviewed. After the second fall, the resident was moved closer to the nurses' station and oxygen tubing was adjusted. b. Fall 12/5/12 - Failure to properly assess Review of a 12/5/12 fall report revealed the following: -Location of fall: Resident's bathroom -Type of fall: witnessed -Contributing factors: Attempting to flush toilet -Incident details: The resident was walking with a certified nurse aide (CNA) to the bathroom. He was using a walker. After using the bathroom the resident leaned forward to flush the toilet and had a total body spasm, the CNA tried to hold the resident, but he moved forward and bumped his head on silver bar causing a bump to the right forehead and causing pain to the right side of the neck, which he had on 12/4/12. Resident fell to his right knee. The resident was assisted up to sit on the closed toilet seat and then assisted back to bed with one staff member and the walker. There was no documentation that indicated the resident was assessed by the nurse either before being assisted off the floor to the closed toilet seat or after. There was no note about his range of motion or a head to toe assessment. The report revealed the initial treatment provided by a registered nurse (RN) was applying ice to the forehead. Review of the NN dated 12/5/12 revealed: -At 4:45 a.m., the NN documented a COC (change of condition), VSS (vital signs stable) and neuros (neurological assessment) WNL. -At 10:00 a.m., a NN documented to continue on incident follow up (IFU) with neuro WNL. Ice applied to right neck and forehead bruise PRN. -At 5:00 p.m., a NN documented the nurse was called to the room because the resident was having a [MEDICAL CONDITION], 911 was called, the resident began to have agonal respirations about every 15 to 20 seconds, cessation of breathing and other vitals noted. There was no indication that the nurse assessed the resident after the fall, other than the neck and the forehead injury. Staff Interviews On 2/12/13 at 1:55 p.m., two CNAs were interviewed. They indicated that anytime a resident has a fall, is lowered to the floor or even goes down on their knees, they should immediately get the nurse. They indicated that the CNAs should never get the resident up off the floor until the nurse had assessed them. On 2/12/13 at 2:05 p.m., a licensed practical nurse (LPN) was interviewed. She indicated that the nurse should always assess a resident immediately following a fall. The findings should always be documented in the NN. She indicated that CNAs should never get the resident up off the floor until the resident has been assessed. On 2/12/13 at approximately 4:00 p.m., the director of nursing (DON) was interviewed. She reviewed the fall incident, dated 12/5/12, and indicated that there was no indication that the resident had been assessed other than the bump to the forehead and the neck pain, that had not been further investigated and was associated with pain from 12/4/12. -She indicated the CNA was the staff member that had helped the resident up off the floor and helped him back to bed. She indicated that the RN had been the one to assess the bump and apply ice. She said it is her expectation that CNAs never assist a resident up off the floor until after the nurse assessed the resident. She also said it is her expectation that the nurses assess the resident immediately after the fall and document the findings. She confirmed that this did not happen on the fall for 12/5/12. 5. Resident #147 Resident #147, age 96, was admitted to the facility on [DATE]. According to the facility admission record, his diagnoses included subarachnoid hemorrhage, urinary tract infection, [MEDICAL CONDITION], dementia with behaviors, [MEDICAL CONDITION], pneumonia, difficulty walking, [MEDICAL CONDITION], and dysphagia. The resident resuscitation status was not to resuscitate in the event of a respiratory or [MEDICAL CONDITION] according to the resident's MOST form outlining the resident/family wishes for end of life care. Record Review Review of the Social Services section revealed that there were no entries at all regarding end of life decisions. Review of the nurses notes (NN) from 12/3/12 to 12/20/12 revealed that the resident's oxygen saturation ranged from 90-92% on 2 liters of oxygen. Further review of NN documented a decline in the resident's condition. Specifically: 12/21/12: -At 4:00 a.m., the resident vomited a large amount of bile. The resident was struggling to breathe, using auxiliary muscles to breathe. The assistant director of nursing (ADON) was notified. The resident's oxygen saturation was 84% on 6 liters. At 4:45 a.m., the son and daughter were at the bedside. There was no documentation that the physician was notified of the resident's struggle to breathe, his low oxygen saturation, or the increase in oxygen flow to 6 liters. There was no documentation of a discussion with the family about their wishes for the resident. -At 9:15 a.m., new orders were received for nebulizer treatments. The resident was treated one time with [MEDICATION NAME] for labored breathing, restlessness and pain. -At 3:20 p.m., the resident's oxygen saturation was 84% on 6 liters. The resident was unresponsive to verbal stimuli. There was no documentation the physician was notified of the resident's status, after the order for nebulizer treatments was obtained. 12/22/12: -At 6:00 a.m., the resident's oxygen saturation was 83% on 6 liters. [MEDICATION NAME] was given twice as well as a nebulizer treatment for [REDACTED]. -At 8:45 a.m., the resident's respirations remain labored. -At 7:30 p.m., resident's respirations were labored with use of auxiliary muscles. Periods of apnea noted with intervals of five seconds. There was no documentation the physician was notified of the resident's status. 12/23/12: -At 7:30 a.m., the resident's oxygen saturation was 84% on 6 liters. The resident's respirations continue to be labored. -At 9:45 a.m., the resident had been unresponsive for the morning. The resident had audible congestion. Family at bedside. There was no documentation that the physician was notified of the resident's status or of discussion with the family related to their wishes for treatment. 12/24/12: -At 5:00 a.m., the resident is having agonal respirations with auxiliary muscle use for breathing. The resident does not respond to verbal stimuli and when eyes are opened they will not focus. Vital signs were as follows; oxygen saturation was 92% on 2 liters, blood pressure 78/44, pulse 104, respirations 29 and temperature 99.1, respirations labored with auxiliary muscle use, occasional periods of apnea [MEDICATION NAME] three to five seconds. Family at bedside. At 12:50 p.m., the family reported that he resident was not breathing. Nurse confirms cessation of vitals. Interviews On 2/12/13 at 2:00 p.m., a licensed practical nurse (LPN) was interviewed. She indicated that the physician should be notified immediately anytime there is a change of condition and the physician should continue to be notified if the resident's condition continues to decline. On 2/12/13 at approximately 3:06 p.m., the director of nursing (DON) was interviewed. -After reviewing the resident's chart, she indicated that the nurses should notify the physician with any change of condition and that the nurse notifying the family should discuss the options and see if they want to treat. She indicated that the resident not being able to breathe was a concern. -She indicated that it was her expectation that the nurse continues to notify the physician if the resident continues to decline or if they are unable to reach the physician. -She confirmed that there was no documentation regarding a timely notification of the physician with the initial change of condition or after the first notification. -She confirmed that being a do not resuscitate (DNR) does not mean that the resident should not receive treatment like antibiotics or treatment to ease breathing. -She confirmed there was no documentation regarding a discussion with the family about their wishes for treatment. 6. Resident #22 Resident #22, a [AGE] year-old female, was admitted to the facility on [DATE]. According to the face sheet, the resident diagnoses included [MEDICAL CONDITION], mental disorder, [MEDICAL CONDITION], hypertension, and anxiety state. The quarterly Minimum Data Set (MDS), dated [DATE], showed the resident had a short- and long-term memory impairment. She required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. a. Record Review According to the non-pressure ulcer skin impairment care plan, dated 7/3/11, the resident had a skin impairment related to lesion on face, co-morbid conditions, and thin, fragile skin. Approaches included: --Wound care as ordered --Refer to dermatologist as needed --Monitor for pain/discomfort --Monitor for changes On 2/6/13 at 3:03 p.m., the resident was observed in her room. She was lying in bed with her head slightly elevated. The resident was observed to have a reddened lesion on her left temple along with approximately five, small scabbed areas on her face. On 2/11/13 at approximately 8:35 a.m., the resident was observed sitting in the dining room eating breakfast. Approximately five scabs were noted to the resident's face. On her left temple, a raised lesion with a dark reddened scabbed area was again noted. According to the current physician's orders, the resident was to have a weekly head-to-toe skin assessment completed on her bath day. The weekly head-to-toe skin checks were reviewed back to January 2013. The assessments showed the resident's skin was documented to be intact with no issues other than bruising to her lower extremities on the following days: --1/3/13: Skin intact --1/10/13: Skin intact --1/21/13: Skin intact --1/24/13: Skin intact --1/31/13: Skin intact --2/7/13: Skin intact The resident's nursing progress notes were reviewed back to November 2012, and no documentation regarding the resident's scabbing or lesion on her face was noted. There was no indication the resident's physician was notified. b. Staff Interview On 2/12/13 at 8:40 a.m., the assistant director of nursing (ADON) stated the resident's face was usually dry, but she had not noticed a lesion. She said, "I will make a note for the nurse practitioner to look at it." On 2/12/13 at 9:27 a.m., the ADON stated she had looked at the resident's face and it was different from her baseline, adding, "I have not seen the scabbing be that pronounced." The ADON said the scabbing and [MEDICAL CONDITION] should have been noted on the weekly skin assessment and further assessed. c. Facility Policy According to the facility's skin management policy, in pertinent part: "Skin assessment findings will be documented weekly on the Head to Toe Skin Check form. Alterations or changes in skin integrity, any break in the resident's skin including skin tear, bruises, abrasions, ulcers, rash, surgical wounds, etc., are to be recorded on the Head to Toe Skin Check form. A Change of Condition form is to be completed and new physician's orders obtained for new incidence of compromised skin integrity."

Based on record review; observation; and staff, resident and family interview, the facility failed to ensure each resident received and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for five of 37 sample residents. Specifically, the facility failed to: -Respond appropriately to resident #2's emergency situation. The resident was found unresponsive but cardiopulmonary resuscitation was not immediately initiated. The resident was emergently admitted to the hospital and expired. -Provide adequate bowel management interventions for residents #16 and #136, resulting in hospitalization and fecal impaction for resident #16; -Adequately assess and treat pain for residents #51 and #133, resulting in the residents continuing to experience pain; The finding included: I. INADEQUATE EMERGENCY RESPONSE A. Facility Policy According to the facility's medical emergency management policy in pertinent part: -"The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's airway, breathing, and circulation are maintained until emergency personnel arrive. Staff is aware of each resident's advance directives prior to the administration of cardio-pulmonary resuscitation (CPR)." -"Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure(s), and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive." B. Resident #2 According to the face sheet, sample resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review According to a physician's telephone order obtained on [DATE] at 5:45 p.m., "Resident would like to be a full core," meaning potentially lifesaving interventions would be taken in the event of an emergency. A nurse's note completed by RN #1 with multiple times entries, dated [DATE], showed: -1:00 a.m., "Sleeping. No c/o (complaints of) pain/discomfort." -4:15 a.m., "Assisted to bathroom by CNA (certified nurse aide). Resident alert and oriented. Conversing with staff. No c/o pain or discomfort." -5:22 a.m., "Resident found with no vital signs. Non-responsive. CPR started. Called 911." -5:23 a.m., "Called DON (director of nursing) and informed her of situation." -5:24 a.m., "Called spouse. Left message for spouse to call (the facility) regarding (resident #2)." -5:30 a.m., "Paramedics here to take over CPR." -5:35 a.m., "Called (spouse) and informed him that his wife was found unresponsive with no vital signs a few minutes ago. Staff started CPR and called 911 and the paramedics are here now with (resident #2) and will be taking her to (the hospital)." -5:50 a.m., "Paramedics left with resident to take her to (the hospital)." -5:55 a.m., "Talked to nurse at (the hospital) and gave her report on resident." -6:00 a.m., "Called (the on-call physician) and received order to transfer to ER (emergency room ) for eval(uation)." -6:45 a.m., "ER nurse called to ask for insurance information for (resident #2) as the insurance company name was not on the face sheet and that since the patient had expired, the patient's husband was in shock and not able to give them this information ..." According to the [DATE] emergency room report in pertinent part: -"The patient is a [AGE] year old female who presents with cardiorespiratory arrest ... patient found down 35 minutes prior to arrival. (CPR) started by a bystander (at 5:20 a.m.) and emergency medical service advanced cardiac life support start time (5:30 a.m.)." -"U/S (ultrasound) of the heart initially showed minimal cardiac activity but this deteriorated and eventually there was no cardiac activity with agonal rate. Pronounced dead. Long discussion with family concerning events." Staff Interview On [DATE] at 4:45 a.m., RN #1 was asked the protocol for when a resident is found unresponsive. She stated the nurse was to assess the resident, start CPR if needed, and call the doctor. On [DATE], a certified nurse aide (CNA #1) stated if she discovered a resident unresponsive, she would contact the nurse to assess the resident. On [DATE] at 8:00 a.m., RN #2, who was working on the East hall the morning the resident was found unresponsive was interviewed. She stated she received a call that morning from RN #1 who was working on the West unit where resident #2 resided. She said RN #1 reported to her that she had just found the resident dead. RN #1 stated the resident was a full code but that she had to finish passing medications. RN #2 stated she immediately left the East unit to attend to resident #2 at the West unit. She stated no one was in the room with the resident and the resident's skin was still warm and pink. She then began CPR. On [DATE] at approximately 9:00 a.m., the DON stated she was not sure if RN #1 knew how to respond to finding the resident unresponsive or how to perform CPR. She said an investigation was conducted. Investigation The facility's investigation into this matter was initiated on [DATE]. It revealed: -"Resident assisted to BR (bathroom) per CNA #2 at approximately 4:15 a.m. Returned to bed - alert, oriented - had conversed with CNA. At approximately 5:22 a.m., (RN #1) to resident's rm (room) to give AM meds and was found unresponsive. (RN #1) alert(ed) CNA #2 - attempt to arouse unsuccessful. (RN #1 went) to desk to check CPR status - full COR. (RN #1) alerted (RN #2). (RN #2) to resident RM, initiated CPR with (CNA #3) and (CNA #4). CNA called 911 from rm. (RN #1) at desk preparing transfer paperwork, called DON, residents husband. Paramedics took over CPR - transferred to hosp(ital). CPR initiated timely. " Action taken following the investigation in pertinent part: -Education/counseling provided to (RN #1) that RN on unit of emergency is lead RN to assess and to initiate CPR after verification of CPR status, to delegate CNA staff as needed, to notify 911, MD, and family. -Expectation is to have nurses perform CPR unless critical situation when a CNA can assist then to have the other RN take over CPR. -Expectation is that (RN #1) is required to attend an outside CPR education course within 60 days. -Final written counseling given to (RN #1) regarding performance of position responsibilities. -Review that nurse to delegate duties to CNA staff. Further Staff Interview On [DATE] at 12:05 p.m., CNA #2, who was the last person to interact with resident #2, was asked about the events that occurred on [DATE]. She said, "It was towards the end of the shift and I was doing my last rounds and doing my room checks to make sure everyone was okay. I got a resident up and into the restroom. He went to the restroom and I went across the hall to check on (resident #2). She was getting up to go to the bathroom and she went into the restroom. She seemed alert and okay. She was talking and laughing. She was excited about the holidays and seeing her family. I told her I would go across the hall as the other resident was going back to bed. I helped him and then I helped her. She was out of the bathroom and she sat on her bed. I left her room at 3:45 a.m. I went up the hall and said I would check back on her. I went to the nurse's station and I was charting and it was about 4:23 a.m. (RN #1) came down and said, "(Resident #1) is gone." I went back to her room and I was trying to wake her up and was shaking her. (RN #1) then said, "See I told you she's dead." The resident was warm and I was trying to wake her up. (RN #1) left the room. I went back down the hall and another nurse (RN #2) from East came over and said grab the crash cart and two other coworkers went in there and started CPR." CNA #2 added, "I don't understand why (RN #1) didn't know (resident #2) was a full code and I don't know why she didn't start CPR. I wish we would have known what to do. I wish my nurse would have stepped up and done what she was supposed to do. She never went back into that room." On [DATE] at 1:34 p.m., CNA #3 was then asked about the events that occurred on [DATE]. She said, "I was going down my hallway on the East unit. One of the girls ran past me and said there's a code and we need help. I went to the resident's room and (RN #2) was in there and we performed CPR. I pumped the air mask. It was very unorganized and very crazy. The only reason why I stepped in is because no one else did and the nurse needed help." On [DATE] at 4:19 p.m., RN #2 was again interviewed. She said, "I received a phone call (from RN #1) at 5 a.m. stating, "I just found a patient dead. She is a full code but I'm in the middle of passing my meds." I told her we have to start CPR and I hung up and found my aides. (Resident #2) seemed calm. She was pulseless and pink, warm and unresponsive." She stated RN #1 did not come into the room at all to check on the status of the CPR or to follow-up. She stated she believed it took approximately six minutes from the time RN #1 discovered the resident unresponsive to when she began CPR. On [DATE] at 4:57 p.m., the DON stated she expected RN #1 to work in collaboration with the other RN during the emergency situation, to validate CPR status and to get CPR initiated. She said, "I felt that as a charge nurse, she needed to be accountable. I would have expected her to act as a supervisory role as well as the nurse in delegating." On [DATE] at 1:42 p.m., RN #1 was asked about her finding resident #2 unresponsive. She said, "I went to give her morning medication and found her unresponsive and not breathing. I went to check her CPR status and I found she was a full COR. I called the nurse on the East nurses station and told her we needed to start CPR. I did tell the CNA that she was unresponsive." -When asked her reasoning for contacting RN #2 instead of attending to the emergency, she stated, "I just thought the situation needed assistance from her." -When asked her the reason she did not follow-up on the status of the emergency situation after CPR was initiated she said, "I don't remember why I didn't go back in there." -When asked if she would handle the situation differently now, she said, "I would have directed the CNA to call for help and I would have immediately started CPR." II. INADEQUATE BOWEL MANAGEMENT A. Facility Policy/Procedure On [DATE] at 4:15 p.m., the Director of Nursing (DON) provided the facility policy entitled "Nursing Monitoring of Bowel Movement" (undated) which documented: "Procedure: The 10 p.m. to 6 a.m. nurse will pull off the computer a list of those residents who have not had a bowel movement reported in the last nine shifts. The 6 a.m. to 2 p.m. nurse will give prune juice with breakfast. The 2 p.m. to 10 p.m. nurse will give Milk Of Magnesia or alternative laxative as ordered. The 10 p.m. to 6 a.m. nurse will give a suppository and evaluate for impaction. Write (document) in the box under your shift and any PRNs (as needed) given and record on the Medication Administration Record (MAR). Any time a bowel movement is reported; document the bowel movement on this sheet. At the beginning of the 2 p.m. to 10 p.m. shift, the charge nurse should recheck the kiosk if bowel movements had occurred. Each nurse receiving the cart should be given this sheet. The night nurse will file in the bowel movement record book each night." -The DON stated on the 15th shift with no bowel movement the resident's physician would be called for additional orders for interventions or for transportation to the emergency room (see interviews below). B. Resident #16 - Fecal Impaction Resident #16 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS), dated [DATE], revealed short and long-term memory loss. She was not understood nor did she understand others. She was totally dependent for all activities of daily living. She was incontinent of bowel and bladder. She was non verbal. Care Plan: The resident's care plan, dated [DATE], identified risk for constipation, but was not updated after the resident experienced a fecal impaction (see hospital reports below). The care plan approaches were: -Administer medications per physician's orders [REDACTED]. -Listen for bowel sounds -Encourage fluid intake -Palpate abdomen for distention, tenderness, mass prn (as needed) -Encourage warm fluids in AM to stimulate BM -Initiate BM protocol if no BM in nine shifts -Offer prune juice every day at lunch -Added on [DATE]: Discontinue [MEDICATION NAME] per family request. Medical Record Review: The resident's medications, in pertinent part prior to her hospitalization , were: -MOM 30 cc every six hours as needed for constipation, -[MEDICATION NAME] suppository 5 mg as needed for constipation. -[MEDICATION NAME] 5 mg delayed release 1 tablet as needed for constipation. -4 ounces of prune juice at lunch daily. hospitalization : According to the medical record, the resident was sent to the hospital on [DATE] due to decreased bowel sounds, distention, nausea and vomiting. Hospital reports: Review of the x-ray report done at the hospital on [DATE] at 7:48 a.m., revealed: Gas throughout the large and small intestines in a pattern suggestive of an ileus, however, in the setting of a large (approximately 13 cm diameter) rectal stool ball this more likely represents a fecal impaction with obstipation. (According to Lippincott, Williams and Wilkins 2006 the definition of obstipation is intestinal obstruction, severe constipation.) Impression: 1. No evidence of an acute [MEDICATION NAME] process. 2. Obstipation secondary to rectal stool ball and fecal impaction. Hospital History and physical: Impression - [AGE] year old demented woman from the nursing home with a urinary tract infection and obstipation. She also has [MEDICAL CONDITION]. Hospital Discharge Summary: The resident was admitted , hydrated and given multiple enemas. She was diagnosed with [REDACTED]. Pertinent medications upon discharge were: [MEDICATION NAME] as needed, MOM, Saccharomyces (Florastar), [MEDICATION NAME] 17 grams twice a day, and [MEDICATION NAME] 2 tablets twice a day. Facility Notes and Reports: Review of nurse's notes revealed no notes concerning constipation from [DATE]-[DATE]. On [DATE], according to the nurse's notes, a [MEDICATION NAME] suppository was given for constipation, results pending. Written in a tiny space between the note and the signature was a large BM at 6:30 p.m. The next nurse's note was on [DATE] at 1:30 a.m. - "Suppository given for constipation. Small soft stool in rectum. 10 a.m. large BM." On [DATE], the nurse was called to room by a CNA. The resident's abdomen was distended and firm. Very hypoactive bowel sounds. Large soft stool in rectum. "[MEDICATION NAME] suppository after removing 2 small 3 cm by 3 cm pieces of soft stool. Raised head of bed and resident immediately had a very large emesis of stooling looking material, heme positive." Received orders to transfer to the hospital. Care Tracker Documentation of BMs: -From [DATE]-[DATE], there were only five BMs documented in care tracker. -From [DATE]-[DATE] for 13 shifts there were no BMs documented in care tracker. -From ,[DATE]-[DATE] for nine shifts there was no documentation in care tracker. (See above nurses' notes, on [DATE], the resident was given a suppository for constipation, results pending. Then in a small space between the note and the signature was written 6:30 large BM.) -[DATE]-[DATE]. A period of 17 shifts, there were no BMs documented in care tracker. -[DATE]-[DATE], a period of nine shifts, there were no results listed in care tracker. Staff interviews: The charge nurse was interviewed on the afternoon of [DATE]. She stated she thought there was other documentation. She stated they had a BM book that used care tracker to notify her that nine shifts had passed and the bowel protocol needed to be implemented. She stated that she would check that book. She said the Bowel Protocol was: after nine shifts the resident will be given prune juice, if no results by the next shift MOM would be administered. If no results by the next shift an enema would be administered. -The charge nurse continued that according to the BM book, prune juice had been given on [DATE] resulting in a loose medium BM. On [DATE], the resident received prune juice and had a small BM. There was no indication of the time the prune juice was given or when there were results. In addition, there was no clarification that the prune juice was given in addition to the routine prune juice the resident received (see care plan above). There were no nurse's notes or care tracker notes. -The charge nurse stated that they had a new procedure for tracking BM's with the care tracker as the main source of information. The DON and the regional nurse and the resident's personnel physician were interviewed on [DATE] at approximately 10 a.m. The DON stated they had followed their protocol and did not know why the resident had an obstruction. However, the findings revealed the facility failed to implement their protocol for BM management. There were no nurse's notes documenting BMs from [DATE]-[DATE]. Then there was another lapse in documentation until [DATE]. In addition, there were no nurse's notes from ,[DATE]-[DATE], even though there were 48 shifts with only four BMs. Documentation further revealed: -The 13 shifts from ,[DATE]-[DATE] revealed prune juice given on [DATE]. There were no results documented in the BM book, the nurse's notes or care tracker. -The 17 shifts from ,[DATE]-[DATE] prune juice and a suppository were given on [DATE]. However there was no documentation when these were administered, no MOM was given per protocol, and no results recorded in the BM book, care tracker or nurse's notes. -The nine shifts from ,[DATE]-[DATE], revealed no indication that additional interventions were put in place. -During 48 shifts from ,[DATE]-[DATE], only four BMs were documented on care tracker. -The charge nurse (see above) stated there were other notes in the BM book, the MAR and nurse's notes. However, there was no coordination between these sources of information to monitor the resident's bowel movements. Family Interview: The resident 's husband was interviewed on [DATE] at 4:00 p.m. When asked if the resident had exhibited any signs and symptoms of constipation. He stated the main change was her breath. He stated her breath was "so rank you could not get close to her." -He further stated that getting more fluids would help with the constipation. He stated the resident no longer knew when she was thirsty. When asked why he wanted the resident's [MEDICATION NAME] stopped, he stated that she had too many loose stools. C. Resident #136 On [DATE], resident #136, [AGE] years old, was admitted to the facility. The face sheet documented the resident had the following Diagnoses: [REDACTED]. The MDS, dated [DATE], documented the resident had a BIMS (cognition) score of 15, indicating no cognitive problems. The resident did not have any short or long-term memory problems. The resident required limited one person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident did not have any upper extremity or lower extremity impairments. The resident was always continent of bowel. The resident was not documented as having a bowel pattern of constipation. Care Plan - Constipation, dated [DATE], documented the resident was at risk for constipation and would have a bowel movement at least every nine shifts over the next 90 days. The care plan documented approaches were to administer medications as physician ordered, record bowel movements on care tracker, auscultate for bowel sounds as needed, palpate abdomen for distension, tenderness and masses as needed. The care plan also documented to initiate the bowel protocol if the resident did not have a bowel movement in nine shifts. The Resident Bowel and Bladder by Shift form did not document the resident had a bowel movement for the following time periods: -[DATE] shift three through [DATE] shift two a total of 12 shifts: (four days), -[DATE] shift two through [DATE] shift three a total of 14 shifts: (four days & two shifts), and -[DATE] shift one through [DATE] shift three a total of 12 shifts: (four days). Nursing Daily Skilled Summary notes, dated [DATE] through [DATE], did not document the resident had any bowel movements, was palpated for abdominal tenderness/distension, was auscultated for abdominal bowel sounds, or was provided any bowel movement interventions. A Doctor's Progress Note, dated [DATE], documented the resident had a soft non-tender abdomen with positive bowel sounds. Medical Record Review: Nursing Daily Skilled Summary notes, dated [DATE] through [DATE], did not document the resident had any bowel movements, was palpated for abdominal tenderness/distension, was auscultated for abdominal bowel sounds, or was provided any bowel movement interventions. The Nursing Monitoring of Bowel Movement form, dated [DATE], documented the resident received four ounces of prune juice on the ,[DATE] shift, Milk of Magnesia on the ,[DATE] shift and a [MEDICATION NAME] suppository on the ,[DATE] shift: no bowel movement results were documented on this form. A Nurse Practioner's note, dated [DATE], documented the resident had abdominal pain and constipation. The note also documented the resident had a soft, rounded non-tender abdomen, normal bowel sounds with no rebounding or guarding. A Nursing Daily Skilled Summary note, dated [DATE], documented resident complained of pain in lower left quadrant of abdomen with movement. [MEDICATION NAME] suppository was given per protocol for no bowel movement in last nine shifts. Nursing Daily Skilled Summary notes, dated [DATE] through [DATE], did not document the resident had any bowel movements, was palpated for abdominal tenderness/distension, was auscultated for abdominal bowel sounds, or was provided any bowel movement interventions. The Nursing Monitoring of Bowel Movement form, dated [DATE], documented the resident had prune juice on the ,[DATE] shift and refused Milk of Magnesia on the ,[DATE] shift. Staff Interviews: On [DATE] at 2:38 p.m., a Resident Care Specialist (RCS) #1 stated she placed documentation of a resident's bowel movements in care tracker as soon as she could or by the end of the shift. She stated the documentation she placed in care tracker was accurate. On [DATE] at 2:42 p.m., RCS #2 stated she kept a running total in her head of the residents who had bowel movements and placed this documentation in care tracker when time permitted or by 10:30 p.m. She stated the documentation in care tracker was pretty much accurate. On [DATE] at 3:00 p.m., a Licensed Practical Nurse (LPN) stated she believed the documentation in care tracker was accurate. She stated the names of residents who have not had a bowel movement in nine shifts, was documented on the daily Nursing Monitoring of Bowel Movement form and was kept in the top right drawer of the medication cart. She stated when a resident who was on this form had a bowel movement the bowel movement was documented on the form as well as in care tracker. On [DATE] at 3:14 p.m., RCS #3 stated she placed documentation of a resident's bowel movement in care tracker as soon as she could after helping the resident get completely settled after having a bowel movement. She stated the documentation she placed in care tracker was accurate. On [DATE] at 3:23 p.m., RCS #4 stated the information in care tracker was accurate. She stated she placed documentation regarding a resident's bowel movement in care tracker as soon as time permitted. On [DATE] at 3:33 p.m., the Resident Care Management Director (RCMD) stated she believed the documentation in care tracker was accurate the majority of the time. On [DATE] at 4:15 p.m., the DON stated it was her expectation nursing staff following the facility policy on Nursing Monitoring of Bowel Movements. On [DATE] at 10:00 a.m., the DON observed/agreed the resident did not have a documented bowel movement on the Resident Bowel and Bladder by Shift form for the following time periods: [DATE] shift three through [DATE] shift two a total of 12 shifts: (four days), [DATE] shift two through [DATE] shift three a total of 14 shifts: (four days and two shifts), and [DATE] shift one through [DATE] shift three a total of 12 shifts: (four days). On [DATE] at 2:37 p.m., the DON stated it was her expectation nursing staff document in care tracker accurately and in a timely manner. III. INADEQUATE PAIN MANAGEMENT A. Facility Policy Review of the facility pain management policy was as follows: Practice Guidelines: 1. Upon admission, residents will be assessed for pain by using the "Nursing Admission Assessment" form. 2. Residents will be screened for pain by using the "Monthly Summary (Briggs);" and the "Pain Evaluation" quarterly, annually and with a significant change and/or new onset of pain. a. Pain intensity and pain relief will be evaluated and re-evaluated at regular intervals. b. These evaluations will be used by the IDT to decide the appropriate therapeutic intervention, which may include pharmacological and non-pharmacological techniques. 3. Additionally, any resident report of inadequate pain control or identified with a new onset of pain, displays new signs or symptoms of pain, or identified through the RAI process or otherwise will have a full evaluation of the pain conducted using the "Pain Evaluation Form;" 4. Following the pain evaluation, notify the physician of the findings and document on the "Change of Condition" form (Briggs). Implement new orders as received. 5. Each resident identified for pain will have a "Pain Management Care Plan (Briggs)." The care plan will have individualized interventions related to that resident's individual control of pain management. The care plan should include both pharmacological and non-pharmacological pain management interventions. RCS assignment sheet/care kardex updated if appropriate. 6. The licensed nurse will implement a "Pain Medication Administration Record" in the medication administration record (MAR) binder for documentation of pain, interventions, and outcomes. 7. The licensed nurse will communicate any new onset of resident pain or change in resident pain through the 24 hour report process. 8. The IDT will discuss the new onset of pain at the daily stand-up meeting and the IDT team conference. 9. The "Pain Management Care Plan" with interventions will be updated as indicated and discussed at the IDT stand up meetings, as needed. 10. The staff will implement the care plan, monitor the resident, and administer therapeutic interventions for pain if ordered; 11. The licensed nurse, when administering narcotic pain medications, will record the drug administration on the "Pain Medication Administration Record; 12. The "Pain Medication Administration Record" guidelines are: a. The pain medication administration record will be used when a resident is receiving scheduled narcotic medications for pain even if the pain is controlled. b. If the pain is new onset, breakthrough, unstable, or uncontrolled regardless of the type of medications used, the pain medication administration record will be used. c. Documentation for the pain medication administration record is as follows: record the pain scale using the faces rating scale ,[DATE], record the pharmacological interventions attempted, record the non-pharmacological interventions attempted, record the follow-up observations post intervention. If resident is asleep or resting, document it as an observation. 13. At any time through the process of pain management, the IDT may conduct a care management risk review meeting on the resident in conjunction with other risk areas reviewed. IDT referral to rehab as needed. 14. Monitoring of the pain management program will be completed monthly as the "Quality Assessment & Assurance Committee" meetings for successful outcomes and to identify areas for improvement as needed. B. Resident #51 Sample resident #51, [AGE] years old, was admitted to the facility [DATE]. According to the ,[DATE] computerized physicians order (CPO), the resident had [DIAGNOSES REDACTED]. According to a quarterly MDS, dated [DATE], the resident scored a "14 "on the BIMS which indicated minimal cognitive deficits. She understood others and was easily understood. The resident was alert and oriented. She required extensive assistance with bed mobility and transfers with assistance of two plus staff persons and a mechanical lift. The resident was identified as having occasional mild pain during this review period. Record review: Review of the ,[DATE] CPO documented the following [MEDICATION NAME]: -[MEDICATION NAME] 300 mg (milligram), 1 tablet by mouth at HS (bedtime). Dx: [MEDICATION NAME] DM (diabetes mellitus) [MEDICAL CONDITION]. Start date: [DATE]. -[MEDICATION NAME] ,[DATE] mg (milligram), 1 tablet by mouth at HS (bedtime) -Tylenol for pain not to exceed 3000 mg/24 hrs. Start date: [DATE]. -[MEDICATION NAME] ,[DATE] mg (milligram), 1 tablet by mouth, q (every) 4 hr (hours) PRN (as needed) for moderate pain; Tylenol not to exceed 3000 mg/24 hrs. Dx: moderate pain. Start date: [DATE]. -[MEDICATION NAME] (Tylenol) 650 mg (milligram), 1 caplet by q (every) 6 hr PRN (as needed), not to exceed 3000 mg/24 hrs. Start date: [DATE]. -[MEDICATION NAME], 1 po (by mouth) q (every) day at 1:00 p.m. Dx: pain. Start date: [DATE]. -[MEDICATION NAME] 50 mg (milligram), 2 tablets by mouth, TID (three times a day) for moderate pain. Start date [DATE]. Review of a pain care plan initiated on [DATE] and last reviewed on [DATE], documented the following problem/need: "pain, related to; recent fall (resident with hx of falls prior to admission), musculoskeletal, chronic disease process, back surgeries and a broken tooth." Goals were: "...will have increased function/ADL abilities associated with decreased pain over next 90 days." Approaches: "positioning/support, exercise program/stretching exercises, relaxation, distraction/encourage ambulation, administer [MEDICATION NAME] as ordered, implement pain management flow sheet, observe resident for signs and symptoms of pain, including verbal expressions and non-verbal expressions; monitor q (every) shift and PRN (as needed), notify physician if interventions are not consistently effective, medicate resident for pain prior to treatments and therapy, if indicated ..." Review of the latest pain assessment found in the clinical record, and dated [DATE], documented the resident as having occasional pain in the past five days and she had received routine and as needed pain medication but no non-medication intervention. The resident's pain did not affect her sleep or daily activities. The location of the resident's pain was documented in her joints, bone, knees and back. The resident rated her pain at "5" and her pain was controlled at that time. The resident's pain was documented to be relieved by rest, positioning, heat/warm compress, therapy and medications. The assessment documented contributing factors to the resident's pain was due to repositioning, exercise/mobility/ROM, bathing and in association with ADL'S (activities of daily living). Review of the physicians progress notes for ,[DATE] and most recently an annual visit during ,[DATE] revealed no documentation the resident's pain regimen was reviewed. Review of the ,[DATE] MAR for routine and PRN pain med usage revealed that PRN [MEDICATION NAME] ,[DATE] mg (milligram) was administered 12 times (,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE]). As needed [MEDICATION NAME] 650 mg (milligram) was administered three tim

Based on observation, record review and staff and resident interview, the facility failed to ensure the resident environment, including the environment for three (#7, #8, #14) of 19 sample residents, remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, -Resident #14 fell from a toilet riser, causing bruising and pain; -For residents, including, #7, #8, and #14, toilet risers were not maintained to prevent accidents; and -One Oxygen tank was improperly stored. The findings include: A. Toilet Risers 1. Resident #14, age 63, was admitted to the facility 6/22/09. According to the 6/10 computerized physician orders, [DIAGNOSES REDACTED]. According to the 5/22/10 Minimum Data Set (MDS), the resident had impaired long-term memory. She had moderately impaired cognitive skill, with poor decisions, and requiring reminders, cues and supervision in planning, organizing and correcting daily routines. She required extensive assistance for bed mobility, transfers, locomotion on and off the nursing care unit, toilet use, personal hygiene and bathing. She was able to eat independently. She was continent of bowel and bladder. a. Fall risk Review of the resident's 6/22/09 care plan for falls (most recently reviewed 6/25/10) revealed the resident was at risk for falls due to a history of falls, poor vision, utilization of assistive devices, decreased muscle coordination, and supranuclear palsy. The goal was the resident's fall risk would be minimized with reduction interventions. Approaches (in pertinent part) included falling star program, encourage resident to ask for assistance, ensure the resident had proper footwear, (7/14/09) resident needed care giver assistance when up, psychotherapist to discuss safety as needed, (12/9/10) discuss safety equipment, (12/21/09) provide assistive devices (wheelchair, electric scooter), place call light in reach, (7/14/09) safety training per therapy staff, (9/24/09) restorative program updates, (12/15/09) medication evaluation as needed, (12/14/10) staff increase safety as needed, (5/25/10) one-to-one inservice with staff as needed, and (6/15/10) maintenance evaluation of equipment. Review of the 12/30/09 resident/facility contract revealed the resident agreed not to stand up and/or transfer unless a CNA (certified nurse aide) or nurse was present to assist her. The agreement was signed by the resident and a facility staff person. b. Fall 6/14/10 with injuries Review of the 6/14/10 Change of Condition (COC) Nurse to Physician Communication (NTPC) revealed that date at 8:30 p.m., the resident was sitting on the toilet having a bowel movement (BM) and told the CNA to leave. She leaned forward and the high rise toilet seat "fell over and broke." She hit her left forehead on a door jamb. (She) complained of a headache. Good range of motion (ROM) all extremities. Family and physician notified, and an ice pack was applied. Review of the 6/14/10 Interdisciplinary Post Fall Review, conducted 6/15/10, revealed the resident sustained [REDACTED]. The fall occurred in the resident's bathroom. The resident was seated on the toilet prior to the fall. She had a history of [REDACTED]. There were no environmental factors that contributed to the fall. The summary of the interdisciplinary team (IDT) was facility maintenance staff was to evaluate the safety of the toilet riser. (See care plan intervention above dated 6/15/10 - maintenance evaluation of equipment) Review of nurses' notes (6/15 - 6/17/10) revealed documentation of resident bruising, tenderness, and discomfort following the fall. -6/15/10 6:00 a.m. revealed the resident was on fall follow-up (f/u). The left forehead bruise was intact. -6/15/10 1:00 p.m. there was left forehead bruising. -6/16/10 6:00 a.m. bruising on forehead above the left eye, tender when touched: bruising was present on the left eyelid. The resident was able to open and close her left eye without difficulty. -6/16/10 11:35 a.m. the resident complained of pain in left hip. She was able to transfer well and able to bear weight without grimacing or guarding. -6/16/10 2000 (8:00 p.m.) the nurse practitioner (NP) examined the resident. Bruising on forehead, complained of discomfort left hip. She transferred well, bearing weight without grimacing. -6/17/10 0500 (5:00 a.m.) there was no pain or discomfort. The bruise to the forehead remained; and -6/17/10 2:00 p.m. the resident denied pain, and had her normal range of motion in all four extremities. Record review (Medication Administration Nurse's Notes for 6/10) revealed on 6/16/10 at 3:00 a.m. the resident skin check showed a bruise on the left side of her forehead because of a fall. The area was described as tender to touch. c. Resident interview and observations On 6/28/10 at 10:45 a.m. the resident sat in a wheelchair seated at the foot of her bed. She was observed to have a dark blue bruise on her left cheek bone, below and lateral to the left eye. The bruise was approximately one-half inch in height and one inch long. The skin of the upper and lower lids was yellow in color. The resident was wearing eyeglasses. In an interview on 6/28/10 at approximately 10:45 a.m., the resident said a few days before, she leaned forward while seated on the toilet to have a BM and fell off the toilet. She said she had previously signed a contract with the facility that she would not stand up or attempt self-transfers without the assistance of an aide (CNA). She said the contract did not specify she could not bend forward when she was trying to have a BM. Observation of the toilet riser on the resident's toilet revealed the riser was a raised white plastic seat that elevated the sitting height of the porcelain commode by four inches. The riser had four metal legs with black rubber tips. The bilateral armrests were metal, covered with a blue foam padding. In the bottom rear of the riser seat was an off-white rigid plastic tab inserted between the porcelain commode and the commode's hinged upright toilet seat and cover. The riser moved side to side on the commode, but the entire device did not lift off the commode when the riser went as far forward as possible on the commode. d. Staff interviews In interview on 6/29/10 at 8:35 a.m. the Restorative Nurse said she was involved in an investigation of the resident's fall. She said the Maintenance Director evaluated the safety of the risers. She said the current style of riser was in place approximately two to four years. She said the CNA who had placed the resident on the commode was not listed as a witness to the event, as she was not in the room when the resident fell . In telephone interview on 6/29/10 at approximately 4:27 p.m. the CNA (CNA #2) who provided care to resident #14 on 6/14/10 (date resident fell ), confirmed she placed the resident onto the toilet riser in her bathroom. She said the resident asked her to step out of the bathroom so she could have some privacy. After ensuring the resident had the call light string in her hand, she stepped out of the bathroom and stepped out into the hallway outside the resident's room so she could see when the call light was lit and the resident was done. -CNA #2 said she heard a loud noise. Resident #14's roommate jumped up at the same time, and the call light went on, too. She said the bathroom door opened and the resident was lying on the bathroom floor on her left side. The CNA said she hollered for the nurse and went to the resident's side. She thought the resident might have struck her head on the bathroom door, as it burst open with such force. -CNA #2 said after the nurse evaluated the resident, and the resident was placed in her bed, she (CNA #2) returned to the bathroom to right the toilet riser and under it, discovered a flat piece of white hard plastic she estimated to be the size of her palm. She left the toilet riser under the bathroom sink, and advised resident #14 as well as the roommate, not to use the bathroom during the night until the toilet riser was replaced. She said she left the piece on the back of the toilet, and after a few days, threw it out. -CNA #2 said no one came to talk to her about the circumstances surrounding the resident's fall. In interview on 6/29/10 at approximately 4:10 p.m. the nurse (#1) on duty on 6/14/10 when the resident fell confirmed she assessed the resident after she fell . -Nurse #1 confirmed the toilet riser was broken below the riser seat, on the left side. She said she was unable to tell if the riser broke before or after the fall. -Nurse #1 was unable to offer further description of the appearance of the damage to the toilet riser. In interview on 6/29/10 at 9:20 a.m. the Director of Maintenance (DM #4) said resident #14's toilet riser was not broken. He said as a result of the resident's fall, he conducted an audit of all toilet risers in the building. He confirmed "a few" of the lock mechanisms were cracked, and he would be ordering the necessary parts. He said he did not have the room by room audit of the toilet riser locking mechanisms. He did not indicate how often the condition of the toilet risers was checked for breaks and/or cracks. In interview on 6/29/10 at approximately 10:00 a.m. a member of the Maintenance Staff (#5) said he put resident #14's toilet riser back on her toilet the morning of 6/15/10. He said the device was on the floor under the bathroom sink, and was not broken. In interview on 6/29/10 at 12:09 p.m. the DM said facility administration had ordered 48 toilets to replace the current porcelain commodes. The height of these toilets would eliminate the need for a toilet riser. The DM described the Safety Committee, which he chaired, meets monthly to discuss identified safety concerns. He said the most recent meeting was 6/27/10, and the concern about the cracked toilet risers was presented in that meeting. He said possible options discussed at this meeting were to replace the toilets for taller ones, or get different types of toilet risers. The problem with attaching any device to the toilet was it had to be removed daily for cleaning, yet remain sturdy for resident use. In interview on 6/29/10 at approximately 3:30 p.m. the Nursing Home Administrator (NHA) said she was told resident #14's toilet riser was not broken, so there was no need to report the equipment to the State Agency (SA) due to equipment failure. e. Observations Observation on 6/30/10 at approximately 10:00 a.m. revealed a Maintenance Staff Person (#5) with the toilet riser locking mechanism. The Y-shaped device was off-white, hard plastic. The locking tab was approximately five inches wide by four inches deep. Moulded into the reverse of the locking tab was "Slip-in Lok-in El." On each of the narrower arms of the "Y" was a one-inch wide by one-inch tall knob which fit into same-sized holes in the base of the plastic toilet riser seat. Observation on 6/30/10 at 2:09 p.m. Certified Nurse Aide (CNA #2) was shown a tracing of the "Slip-in Lok-in El" to see if she could identify any part that resembled the piece she found on the floor (see below). She identified the locking tab as the part that resembled the shape of the piece she found after the resident fell . 2. Failures in facility's response - additional observations of cracked and/or unsecure toilet risers On 6/29/10 at 12:09 p.m. the DM provided a "Facility/State-Specific Checklist" dated 6/16/10 showing "Found several riser (sic) with brackets that need replacing, will contact (name of vendor)." The Preventive Maintenance done was "All toilet risers inspected." a. Facility tours On 6/28/10 at 10:15 a.m., the initial tour of the facility was conducted. On 6/29/10 at 9:40 a.m., the environmental tour of the facility was conducted with the Director of Maintenance (DM) and the Environmental Services Supervisor (ESS) in attendance. (1) Observations documented the following safety/hazard concerns regarding toilet risers on resident commodes: -Room #1: riser moved side to side, -Room #5: riser moved side to side, -Room #32: riser bracket (one side) broken, riser moved in all directions, -Room #37: riser moved side to side, -Room #106: riser broken bracket, riser not locked or secure (moved in all directions), -Room #101: riser broken bracket, riser not locked or secure (moved in all directions), -Room #114: riser broken bracket, riser not locked or secure (moved in all directions), -Room #116: no toilet seat on commode, riser not locked or secure (moved in all directions), -Room #118: riser moved side to side, -Room #119: riser moved side to side, -Room #121: riser moved side to side, four support feet on riser did not touch floor, -Room #124: riser broken bracket, riser not locked or secure (moved in all directions), -Room #126: riser broken bracket, riser not locked or secure (moved in all directions), and -Room #129: riser moved side to side, two support feet on riser did not touch floor. (2) Interview On 6/29/10 during the environmental tour, the DM stated he was working with a supply company (named) to order toilet riser replacement parts; but they had not been ordered as of this date. The DM stated he had conducted an audit of repairs that needed to be conducted on resident toilet risers; however, he did not have a specific room list documenting the needed repairs. The DM stated staff filled out repair requests in maintenance logs located at each nursing station. The logs were reviewed several times each day. The DM also stated resident Ambassadors (staff members) checked rooms on a daily basis for cleanliness and needed repairs. On 6/29/10 at 12:11 p.m., the DM stated on 6/16/10, he had conducted an audit (identified) the toilet risers that needed to be replaced. The DM stated housekeeping staff had not notified him of any concerns with toilet risers prior to the audit on 6/16/10. The DM stated he was trying to find replacement brackets (parts) for the toilet risers and had not fixed/repaired any of the toilet risers since the audit on 6/16/10. The DM provided a Purchase Order #OAS N3798 dated 6/29/10 (during survey) (11:44 a.m.) for 48 ADA (Americans with Disabilities Act) elongated toilets to replace all resident toilets in the facility. The DM stated the new ADA toilets would eliminate the need for toilet risers. (3) Record review and interview On 6/29/10 at 2:01 p.m., the DM provided a Toilet Riser Audit conducted on 6/16/10. The Audit documented the following pertinent information: -Rooms with broken brackets: #1, #30, #32, #105, #107, #126, -Rooms with cracked brackets: #21, #124, and -Rooms needing a toilet seat: #112, #114. Hand written documentation on the audit noted the facility needed at least eight riser brackets and to order toilet seats: call supply company (named). On 6/29/10 at 2:17 p.m., the DM stated again he had conducted the Toilet Riser Audit on 6/16/10. The DM stated he could not purchase riser brackets by himself; rather, he had to go through the supply company (named). The DM stated the supply company told him they would provide the needed brackets to repair the toilet risers; however, as of 6/29/10, he had not received any of the replacement riser brackets (Slip-In Lok-In- E). b. Additional observations of damaged and/or unstable toilet risers (1) Resident number #7, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed total assist with activities of daily living. His cognition was severely impaired with short- and long-term memory loss. He was sometimes understood and could understand sometimes. On the initial tour of the building on 6/28/10 at approximately 10:15 a.m., the resident had returned from dialysis. He stated that he needed to use the bathroom. The resident was assisted with a total body lift to the commode. On 6/28/10 at approximately 11:30 a.m., the resident's toilet riser was examined. There was nothing to hold the toilet riser on the commode. There was no toilet seat to hold on the toilet riser and the toilet riser was just balanced on the toilet. (3) Resident #8, [AGE] years old, was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His MDS, dated [DATE], revealed short- and long-term memory loss with moderately impaired cognition. He was sometimes understood and could usually understand. He was independent with activities of daily living with minimal assist. During the initial tour of the building on 6/28/10 which began at 10:15 a.m., the resident was interviewed. He stated he was supposed to wait for assist with toileting but he often went to the bathroom himself. His toilet riser was inspected on 6/28/10 at approximately 11:10 a.m. The toilet riser had a tab that fit under the toilet seat cover; however, there were cracks on both sides of the tab. The toilet riser also wiggled from side to side. (4) On 6/28/10 at 9:15 a.m. a housekeeper was observed cleaning a toilet on the west side of the facility in room 125. The housekeeper had the toilet riser off the commode and was cleaning around the toilet. There was a place for two tabs to hook to the toilet but one tab was broken off, displaying a jagged piece of plastic still attached to the toilet seat. The housekeeper was asked about the missing piece of plastic. She stated that several toilet risers had broken parts. She was asked if she notified her supervisor of the problem; however, her answer was interrupted by the other staff. B. Oxygen Storage On 6/28/10 at 10:15 a.m., observations revealed one six cubic foot oxygen cylinder (tank) in a black fabric carrying case laying on its side (unchained/unracked) on a wire shelf in the Oxygen Storage Room (OSR). The shelf was attached to the wall approximately four feet off of the cement floor. A Charge Nurse (CN) was immediately notified. The CN observed/agreed the oxygen tank was laying on its side (unchained/unracked) on the wire shelf in the OSR. The CN stated the oxygen tank should have been placed in a rack and she would call maintenance. On 6/28/10 at 11:20 a.m., the Region Care Management Coordinator (RCMC) provided the facility policy on Storage Area Safety OP2 0401.03 (revised 6/07). The policy documented in pertinent part: 8. Oxygen Storage (c) Secure all tanks. OXYGEN STORAGE REQUIREMENTS NFPA 99 - 1999 EDITION (LESS THAN 3000 CUBIC FEET) Division of Quality Assurance - Bureau of Regulatory Compliance (revised 3/04) 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.