Every finding on record at Sloan's Lake Rehabilitation Center

Based on observations and interviews the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease on 2 out of 2 units. Specifically, the facility failed to ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing care to residents who were on enhanced barrier precautions. Findings include: I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, retrieved on 3/9/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high-contact resident care activities. Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident to resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of a gown and gloves for high-contact resident care activities is indicated when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices, regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (ex. central line, urinary catheter, feeding tube, tracheostomy/ventilator), or wound care (any skin opening requiring a dressing). In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.II. ObservationsOn 3/2/26 at 4:20 p.m., the director of nursing (DON) and registered nurse (RN) #1 entered the room to access Resident #17's peripheral inserted central catheter (PICC) to flush and cap. The DON and RN #1 had gloves on. -The DON and RN #1 failed to don a gown prior to provide care to Resident #17 who required EBP related to a PICC line and wounds. On 3/4/26 at 2:50 p.m.Resident #85 was assisted to his room by a physical therapist and certified nurse aide (CNA) #9. CNA #9 and the physical therapist put on gloves. They transferred Resident #85 from his wheelchair to his bed. The physical therapist and CNA #9 proceeded to change his undergarments, which were soiled. -The physical therapist and CNA #9 failed to don a gown before providing incontinence care. III. Staff interviewsRN #1 was interviewed on 3/3/26 at 11:20 a.m. She said the staff needed to wear a gown and gloves when providing care to a resident who was on EBP.The DON was interviewed on 3/3/26 at 11:28 a.m. The DON said the importance of EBP was to prevent the spread of infection. She said the staff should have worn a gown and gloves when caring for Resident #17.The physical therapist was interviewed on 3/4/26 at 2:56 p.m The physical therapist said when a resident was on EBP they needed to wear gloves when providing care. CNA #9 was interviewed on 3/4/26 at 3:05 p.m CNA #9 said enhanced barrier precautions were to wear a gown, gloves, and a mask. LPN #2 was interviewed on 3/4/26 at 3:20 p.m. LPN # 2 said the staff needed to have a gown and gloves on for resident care. LPN #2 said the staff should have worn PPE when assisting Resident #85.

Based on resident observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#12) of four residents reviewed for supplemental oxygen use out of 30 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for Resident #12's continuous oxygen use. Findings include: I. Facility policy The Oxygen Administration Policy, revised March 2019, was provided by the nursing home administrator (NHA) on 1/23/24 at 10:47 a.m. It read in pertinent part, The purpose of the oxygen policy is to provide sufficient oxygen to the bloodstream and tissues. The oxygen administration procedure included obtaining the appropriate physician's order. II. Resident #12 A. Resident status Resident #12, over age 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included atrial fibrillation, hyperlipidemia, cardiac arrhythmia, hypoxia (low blood oxygen) and traumatic brain injury (TBI). According to the 12/30/23 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He was dependent on staff for bed mobility, transfers, grooming, and toilet use. The resident received oxygen therapy. B. Record review Resident #12's oxygen care plan, initiated on 12/11/23, identified the resident had oxygen therapy related to ineffective gas exchange. Interventions included administering medication as ordered by the physician, monitoring for signs and symptoms of respiratory distress and reporting any signs to a medical provider, and applying oxygen via nasal cannula up to 2 liters per minute (LPM) to keep oxygen saturations (oxygen blood levels) at or above 90% and titrating LPM (adjusting up and down) as indicated. -The January 2024 CPO did not include an order for the continued use of oxygen for the resident. C. Observation On 1/17/24 at 2:20 p.m., Resident #12 was seated in his wheelchair in his room with an oxygen cannula in his nostrils. The resident's oxygen concentrator was set to 1 LPM. On 1/18/24 at 9:59 a.m., Resident #12 was lying in his bed with an oxygen cannula in his nostrils. The oxygen concentrator was set to 2 LPM. On 1/18/24 at 1:05 p.m., the resident was seated in his wheelchair in his room with his oxygen cannula in his nostrils set at 2 LPM. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 1/18/24 at 3:19 p.m. CNA #1 said Resident #12 used oxygen continuously via nasal cannula at 2 LPM. The CNA said the resident was currently on 2 LPM and had been on oxygen since the beginning of her shift. Licensed practical nurse (LPN) #1 was interviewed on 1/18/23 at 3:36 p.m. The LPN said oxygen was considered a medication and required a physician's order before administration to any resident. LPN #1 said the resident had a physician's order in place but she could not locate the order in the resident's medical records. LPN #1 said a negative outcome of not having a physician's order for oxygen therapy could be the resident receiving too much oxygen causing hypercapnia (too much carbon dioxide in the bloodstream) or less oxygen causing respiratory distress such as hypoxia (insufficient level of oxygen to the bloodstream). The director of nursing (DON) was interviewed on 1/18/24 at 3:50 p.m. The DON said it was important for the nursing staff to ensure a physician's order was in place for every resident who required oxygen therapy. She said she was not sure why the resident did not have the required physician's order, however, she immediately ordered staff to call the physician's office to obtain an order for oxygen use for the resident. The DON said negative outcomes from administering oxygen without proper physician orders could be altered mental status, dizziness, falls and hypoxic events and could have put the resident in respiratory distress.

Based on observations, interviews and record review, the facility failed to establish parameters for pain medication for one (#105) of five residents in a manner consistent with professional standards of practice out of 30 sample residents. Specifically, the facility failed to: -Ensure pain parameters were established and implemented for physician ordered as needed (PRN) pain medications; and, -Ensure non pharmacological interventions were implemented before administration of an opioid pain medication. Findings include: I. Facility policy and procedure The Pain Management policy, revised November 2019, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:52 a.m. It read in pertinent part, Residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The facility assists each resident with pain to maintain or achieve the highest practicable level of well being and functioning by: screening to determine if the resident has been experiencing pain; comprehensive evaluation of the pain; licensed nurse will complete the licensed evaluation in Point Click Care; and utilizing pharmacologic and/or non pharmacologic interventions to manage and/or try to prevent the pain consistent with the resident's goals. II. Resident #105 A. Resident status Resident #105, age 84, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included rheumatoid arthritis (RA) and sacral fracture. The 1/16/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He required setup assistance with eating, supervision with personal hygiene, partial/moderate assistance with bed mobility and substantial/maximal assistance with toileting. -The assessment failed to indicate if the resident was on scheduled pain medication program, received as necessary (PRN) pain medications or received non pharmacological interventions for pain management. B. Observations On 1/22/24 at 7:35 a.m., certified nurse aide with medication authority (CNA/MA) #1 entered Resident #105's room and asked what number his pain was on the pain scale. Resident #105 rated his pain a 6 out of 10. She asked Resident #105 if he wanted Tramadol or Oxycodone. CNA/MA #1 checked the Resident #105's medication orders and administered Oxycodone 2.5 milligrams (mg) to Resident #105. -She did not verify on the medication administration record (MAR) pain medication parameters or obtain guidance from licensed nursing partners regarding pain medications without ordered parameters. -She did not offer a non pharmacological intervention before administration of an opioid pain medication. C. Record review The pain management care plan, initiated on 1/12/24, indicated Resident #105 was at risk for pain from a pelvic fracture. Interventions included to administer pain medications as ordered, anticipate need for pain relief, follow pain scale to medicate as ordered, monitor/report to nurse resident complaints of pain or requests for pain treatment and pain assessment every shift. -A review of Resident #105's comprehensive care plan did not reveal a person centered approach with identification of location, type or intensity of pain the resident experienced. -The care plan did not include personalized non pharmacological interventions to address the resident's pain. It did not identify a baseline assessment of pain or person centered pain management goals. Review of Resident #105's January 2024 CPO revealed the following physician orders related to pain management: Acetaminophen 1000 mg every six hours as needed for pain management. The date of the order was 1/19/24. Tramadol 50 mg every six hours as needed for severe pain. The date of the order was 1/19/24. Oxycodone 2.5 mg every eight hours as needed for acute pain. The date of the order was 1/18/24. Monitor level of pain every shift using a 1-10 scale, ordered 1/11/24, where: -0 indicated no pain; -1 to 3 indicated mild pain; -4 to 5 indicated moderate pain; -6 to 9 indicated severe pain; and, -10 indicated excruciating pain. -A review of the January 2024 CPO failed to reveal documentation regarding the location and type of the resident's pain being treated by Acetaminophen, Tramadol or Oxycodone. -The physician orders did not include specific pain scale parameters for the PRN Acetaminophen and Oxycodone. D. Staff interviews CNA/MA #1 was interviewed on 1/22/24 at 7:40 a.m. CNA/MA #1 said the Oxycodone did not have specific ordered pain parameters and the Tramadol was ordered for severe pain. She said she let the resident decide which pain medication would be effective for his pain. Registered nurse (RN) #3 was interviewed on 1/22/24 at 9:30 a.m. RN #3 said when a resident was experiencing pain, non pharmacological approaches should be tried first. She said if pain medication was needed a pain assessment should be done first. She said a pain parameter should be ordered. She said Acetaminophen was administered for mild to moderate pain and opioid pain medication was administered for severe pain. RN #3 said if a pain parameter was not ordered for a pain medication the physician should be consulted to obtain pain parameters. The director of nursing (DON) was interviewed on 1/23/24 at 11:00 a.m. She said non pharmacological approaches should be tried first before pain medication was administered. She said pain assessments should be done before administration of a pain medication. She said which pain medication to give was based on physician ordered pain parameters. She said opioid pain medications should have pain medication parameters ordered. She said CNA/MA's should follow the physician ordered parameters for which pain medication to give. She said CNA/MA's should consult their licensed nursing partners if pain parameters were not ordered or not clear. She said she would review Resident #105's MAR for unclear or missing pain medication parameters.

Based on record review and interviews, the facility failed to ensure one (#191) of two residents out of 30 sample residents received dialysis services consistent with professional standards of practice. Specifically, the facility failed to ensure consistent communication and documentation with the dialysis center regarding care and services was completed for Resident #191. Findings include: I. Facility policy and procedure The Renal Dialysis, Care of Resident and Hemodialysis policy, revised December 2020, was provided by the nursing home administrator (NHA) on 1/22/24 at 10:00 a.m. It read in pertinent part, Facility licensed nurses will complete the baseline information, pre and post dialysis section of the nurses dialysis communication record. Dialysis center licensed nurses will complete the dialysis center section of the nurses dialysis communication record. II. Resident #191 A. Resident status Resident #191, age less than 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included end stage renal disease (ESRD). The 1/9/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial/maximal assistance with transfers, partial/moderate assistance with toileting and bed mobility and supervision with personal hygiene. B. Record review The nutrition care plan, initiated 1/4/24, documented Resident #191 was at nutritional risk related to ESRD and dialysis. It indicated the resident received dialysis on Mondays, Wednesdays and Fridays. The fistula (an irregular connection between an artery and a vein created surgically to facilitate dialysis) care plan, initiated 1/8/24, documented the care of the fistula related to dialysis. Interventions included pressure reducing mattress, avoid scratching, good nutrition and hydration and facility protocols. -Further review of Resident #191's comprehensive care plan revealed the facility failed to initiate and implement a resident specific care plan focus for dialysis. On 1/18/24 a review of the hemodialysis communication record forms from 1/5/24 to 1/17/24 revealed the following: -On 1/8/24, a hemodialysis communication form was not on the chart; -On 1/10/24, a hemodialysis communication form was not on the chart; and, -On 1/15/24, a hemodialysis communication form was not on the chart. -Review of Resident #191's electronic medical record (EMR) failed to reveal documentation to indicate communication between the facility and the dialysis center had occurred on 1/8/24, 1/10/24 or 1/15/24. C. Staff interviews Registered nurse (RN) #2 was interviewed on 1/18/24 at 12:30 p.m. RN #2 said the facility nurse filled out the top portion of the nurses dialysis communication form, including vital signs, any medications to be administered during dialysis and other pertinent information. She said the form was sent to dialysis with the resident. RN #2 said the dialysis nurse filled out their portion of the form with information such as medications received, pre and post dialysis weights and other pertinent information. She said the form was supposed to be sent back to the facility with the resident after dialysis. She said this document was a permanent record on the resident's medical chart. RN #2 said if the form did not return to the facility with the resident, nurses should communicate with the dialysis center. She said there had been an issue with the dialysis center consistently not returning the hemodialysis communication form back to the facility with Resident #191 after dialysis. RN #2 said she did not know if nurses had communicated with the dialysis center regarding the missing communication forms. The director of nursing (DON) was interviewed on 1/23/24 at 11:00 a.m. She said the dialysis communication form should be filled out by the facility nurse prior to the resident going to dialysis with vital signs and medications. The dialysis nurse was to document pre and post dialysis weights, medications received and other pertinent information and return the form to the facility with the resident. She said nurses should communicate and document with the dialysis center if this form did not come back with the resident. She said the facility nurses were to check the resident's vital signs and fistula dressing upon the resident's return to the facility and document the information on the dialysis communication form. The DON said this communication should happen every time the resident went to dialysis and the communication form was a permanent part of the resident's medical record. She said receiving dialysis communication forms back from dialysis centers was an ongoing problem. She said Resident #191 had missing dialysis communication forms. She said the information from the forms was important for effective communication and the continuity of care between the facility and the dialysis center.

Based on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs that accommodated resident allergies, intolerances and preferences for two (#106 and #191) of six residents out of 30 sample residents. Specifically, the facility failed to: -Ensure Resident #106 was provided appropriate vegetarian meal items per the menu spreadsheets after the meat was eliminated; -Ensure Resident #191 was provided or offered a substitute meal when the resident did not like the lunch item provided; -Ensure Resident #191 was provided with dinner after a late dialysis appointment; and, -Follow the therapeutic dialysis diet for Resident #191. Findings include: I. Facility policy and procedure The Resident Food Preferences and Meal Alternates policy, revised July 2021, was provided by the nursing home administrator (NHA) on 1/23/24 at 2:32 p.m. It read in pertinent part, Specific food preferences, diet restrictions, and diet history will be gathered upon admission to inform the food service department of the resident's information. Appropriate alternate foods will be prepared and substituted for food dislikes, allergies, and/or intolerances. Upon admission (within 48-72 hours) and periodically as needed, the food service manager or dietician, or designee, will interview the individual for the following information: acceptance of diet order, food preferences, intolerances, allergies, cultural and/or religious preferences, location where the meals are to be served and diet history. Information is included in nutrition evaluation, care plan, and resident meal ticket. The information is kept on file to ensure that each individual's needs and desire for food are met. The food service staff are responsible for preparing and serving the alternates. The food service department will make reasonable accommodations to meet resident preferences and special requests. The food service staff will use the menu substitution lists and menu spreadsheets as a guideline for appropriate, nutritionally balanced substitutions. II. Resident #106 A. Resident status Resident #106, age greater than 65, was admitted on [DATE], and discharged on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included chronic embolism and thrombosis of deep veins of left leg (blood clot), chronic kidney disease, and cerebral infarction (stroke). The 1/7/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required substantial/maximal assistance with toileting hygiene and lower body dressing. She required partial/moderate assistance with bathing, bed mobility, and transfers. She was independent with eating. B. Resident observation and interview Resident #106 was interviewed on 1/17/24 at 2:11 p.m. She said she was a vegetarian. Resident #106 said the kitchen took the meat off her meals but did not substitute another protein. Resident #106 said it was a real struggle when she first admitted because they served her meat. She said the dietary manager (DM) had a meeting with her and now the meat was gone but she was still not receiving a substitute for the protein. She said she knew what was on the menu by the meal slip but she had not seen an always available menu for alternatives. Resident #106 said if she did not like what was on the menu then she was not able to eat. She said she liked peanut butter sandwiches but they were not offered. She said no one had offered her any type of protein shakes. Resident #106 was observed on 1/18/24 at 12:14 p.m. Her lunch tray had dill potatoes, chef's vegetable blend, cornbread and butter and a lemon bar. The resident said sometimes they offered almond milk but it was not offered that meal and she was drinking water. Resident #106 said the food service staff had not offered or provided a meat substitute for her meals. The 1/18/24 menu spreadsheet revealed select vegetarian item to serve in place of the catch of the day. -However no vegetarian protein substitution had been provided to Resident #106. C. Record Review Resident #106's nutritional care plan, initiated 12/31/23 and revised 1/16/24, revealed in pertinent part to honor residents rights to make personal dietary choices and provide dietary education as needed (initiated 1/2/24). -There was no documentation regarding the resident's preference for a vegetarian diet. A grievance was filed on 1/2/24 by Resident #106's representative. The resident's representative said the resident did not eat meat and wanted no meat on her tray. The DM responded on 1/3/24 and said she had spoken to the resident's representative and told her to give dietary services a list of proteins the resident wanted. The DM said she went out and got Resident #106 beans and told her about garbanzo beans. The DM said the resident's representative would provide some of the proteins and to give the resident whatever she would circle on her menu. Other foods requested were vegetable patties and avocados. The DM told the resident and her representative they already had these items in the kitchen. The DM told them if there was any other special request she would be happy to go and buy it. -The meat was eliminated from the resident's meals however no protein substitutions were provided or offered on the resident's meal ticket. -The vegetarian preference was added to the resident's meal ticket but not to the care plan. The 1/5/24 admission nutrition evaluation revealed the resident liked most foods, had no major dislikes and would order preferred foods off the daily menu. -However the evaluation was completed by a PRN (as needed) dietician off site and did not involve an interview with the resident, therefore it had not documented that the resident was a vegetarian. Review of Resident #106's meal ticket revealed the following information regarding the resident's meal and food preferences: -Vegetarian; -Regular portions; -Allergies: None; -Beverages: No preferences; -Dislikes: Eggs; -Prefers: No meats; -Refer to spreadsheet for portion sizes; and, -Note: No meats, make sure food is hot. The bottom of the meal ticket read in pertinent part,, Remember to check the additional diet information above and make appropriate adjustments. -However the meal tickets had no notice for the kitchen to add a vegetarian protein substitute from the menu spreadsheet, therefore no appropriate vegetarian protein meal item was provided after the meat was eliminated. D. Staff interviews Certified nurse aide (CNA) #4 was interviewed on 1/22/24 at 1:58 p.m. She said resident meal tickets came on a paper on the resident's meal tray to be filled out by the resident for the next day's meals. The papers were then taken back to the kitchen when the trays were picked up. CNA #4 said the residents filled out their own orders and she was not involved with the ordering or offering of alternate items. The registered dietician (RD) and corporate registered dietician (CRD) were interviewed on 1/22/24 at 2:11 p.m. The RD said the usual procedure for determining resident's preferences and therapeutic diets was to see all residents within five days of admission to interview the resident, gather information from the chart and to put dietary interventions in place on the care plan. The RD said she would typically see everyone in the facility however she had been off work for over a month and a PRN dietician was reviewing the residents charts remotely and there were no in-person interviews. The RD said the DM interviewed residents and updated the meal tray cards but Resident #106's meal ticket was not updated to a vegetarian diet until after the family filed a grievance with the facility. The RD said if a resident was a vegetarian it should be noted on the admission nutrition evaluation but it had not been done for Resident #106 because the PRN dietician had not interviewed the resident. The RD said if a vegetarian resident did not want the meat the dietary staff had menu extensions (menu spreadsheets) and would substitute a menu item that was similar in nutritional value. The RD said Resident #106's lunch on 1/18/24 was not a complete/healthful meal due to missing the protein substitute. The RD said it would be the kitchen's responsibility to select a vegetarian protein option. The CRD, after having viewed Resident #106's meal tickets from 1/14/24 to 1/19/24, said there should have been a spot for the protein substitution on the ticket for either the resident to write in a preference or for the kitchen to put in an appropriate vegetarian protein option. The CRD said the resident was not regularly getting a food group (protein) substitution which was a concern. The CRD said that was why the in-person interviews of residents were important. The CRD said there was a combination of systems that she needed to address to make the process better and she would do some additional training. 47350 III. Resident #191 A. Resident status Resident #191, age less than 65, was admitted on [DATE]. According to the January 2024 CPO, the diagnoses included end stage renal disease (ESRD). The 1/9/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required substantial/maximal assistance with transfers, partial/moderate assistance with toileting and bed mobility and supervision with personal hygiene. B. Resident interview Resident #191 was interviewed on 1/17/24 at 1:50 p.m. He said he had not spoken to a dietitian since his admission on 1/4/24. He said he was on a renal diet. He said he had been receiving bananas and potatoes which he was not allowed to eat on a renal diet. Resident #191 said he went to dialysis in the evenings. He said the facility did not send dinner with him when he left the facility at 3:30 p.m. He said when he returned at 9:00 p.m., his dinner was usually waiting, cold, for him in his room. He said he was not comfortable eating food left out for an extended period of time. Resident #191 was interviewed again on 1/18/24 at 1:00 p.m. He said when he did not like what was served on the renal diet menu for lunch there was not another option on the menu for him to choose from. He said staff did not offer him an alternative. He said he did not like the alternatives in the always available menu book. He said his family was bringing food from home. C. Observations On 1/18/24 at 12:30 p.m., Resident #191 was observed sitting in the dining area and refused his lunch tray. Staff did not offer an alternative lunch and provided the resident with a cupcake. Resident #191 returned to his room without eating lunch. D. Record review The nutrition care plan, initiated 1/4/24, documented Resident #191 was an increased nutritional risk and was on a therapeutic diet for ESRD and dialysis. Interventions included a physician ordered renal diet, monitor weights and intakes, offer and encourage snacks and fluids and honor resident rights to make personal choices. The 1/9/24 nutrition evaluation documented Resident #191 was particular with the food he ate and he was having difficulty adjusting to the food in the facility. The 1/14/24 nutrition progress note recommendations documented to continue the resident's renal diet as ordered, offer a Prostat (protein supplement) every day for protein needs and to monitor weights and oral intakes. -The nutrition progress note failed to reveal a consultation with Resident #191 regarding therapeutic diet education, food choices, preferences and alternatives. E. Staff interviews CNA #5 was interviewed on 1/22/24 at 2:10 p.m. She said residents were given a meal ticket at noon for the next day. She said if the resident did not like what was on the menu they would mark out what they did not want. A substitution or alternative was not automatically offered or provided in place of what the resident did not want. She said if residents did not like what was on the menu for their diet they could order from the always available menu. The DM was interviewed on 1/22/24 at 2:40 p.m. She said when residents were admitted they were provided education on how the meal ordering system worked. She said residents were also provided education on how to order from the always available menu. She said the RD rounded on every resident to find out resident preferences which were added in the care plan. She said an RD was to see every resident within five days of admission. She said for therapeutic diets, the diet was ordered by the physician on transfer from the hospital. The DM said the RD would round with the resident and review the diet, preferences and restrictions. She said she the facility's usual RD had recently been gone and a PRN RD was working remotely and had completed new resident nutritional evaluations through chart review. The DM said an RD had not seen Resident #191 since he was admitted . She said dialysis centers did not allow food to be sent with residents to dialysis. She said because of food safety Resident #191 should not have his tray left in his room until he returned from dialysis. She said education would be provided for staff to store his tray in the unit refrigerator until he returned from dialysis in the evening.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on one out of two floors. Specifically, the facility failed to: -Ensure a resident's room was cleaned in a sanitary manner; -Ensure that the proper cleaning agent was used to clean a resident's room who was on transmission based precautions; and -Ensure appropriate personal protective equipment (PPE) was worn to clean a resident's room who was on transmission based precautions for Clostridium difficile. Findings include: I. Housekeeping A. Professional reference 1. The Centers for Disease Control (CDC) Frequently Asked Questions for Clinicians about Clostridium Difficile (10/25/22), https://www.cdc.gov/cdiff/clinicians/faq.html, retrieved on 1/25/24 at 10:26 a.m., read in pertinent part, Wear gowns and gloves when entering Clostridium difficile infection (CDI) rooms and during their care. Ensure adequate cleaning and disinfection strategy, ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Use an Environmental Protection Agency (EPA) registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions. (Note: only hospital surface disinfectants listed on EPA's List K are registered as effective against Clostridium difficile spores). 2. The CDC Environment Cleaning Procedures (5/4/23), https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118, retrieved on 1/25/24, read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. B. Manufacturer recommendations According to the Clorox Healthcare Fuzion Cleaner Disinfectant (EPA List K registration #67619-30) manufacturer guidelines. January 2024, retrieved from https://www.cloroxpro.com/products/clorox-healthcare/fuzion/ on 1/25/24 at 11:05 a.m. Remove gross soil if visible, For Clostridium difficile spores and tuberculosis (TB), always clean the surface prior to disinfecting. Spray 6-8 inches from the surface until the surface is completely wet. Disinfect by leaving solution on surface for Clostridium difficile spores two minutes of contact time. Wipe with a clean damp cloth. Allow to air dry. C. Observation On 1/23/24 at 9:30 a.m., housekeeper (HS) #1 cleaned resident room [ROOM NUMBER] following the resident's discharge from the facility. The resident had been on transmission based precautions for Clostridium difficile. The following observations were made: HS #1 entered the resident's room after donning gloves and placed the resident's belongings into plastic bags. -HS #1 did not put a protective isolation gown on prior to entering the room. HS #1 sprayed the fall mats, bedside table, nightstand, bed and recliner chair in the room lightly with Oxivir, a disinfectant, and immediately began wiping the disinfectant off the surfaces without allowing the disinfectant to remain on the surface for an appropriate dwell time (the amount of time a disinfectant needs to remain on a surface without being wiped away or disturbed to effectively kill germs). -Oxivir is a disinfectant which is not on the EPA List K for disinfectants effective against Clostridium difficile. -She cleaned from a low area and proceeded to a high area. HS #1 sprayed the bathroom vanity, sink, toilet, shower and commode chair lightly with Oxivir. -The surfaces were not visibly wet. -HS #1 used Oxivir, a disinfectant not on the EPA List K for disinfectants effective against Clostridium difficile. HS #1 wiped the top of the toilet bowl, underneath the toilet seat, tank of the toilet and down the outside of the toilet bowl. -She cleaned the toilet from a dirty area to a clean area and from a low area to a high area without changing gloves, rags or performing hand hygiene. HS #1 turned on the shower and rinsed off the commode with water. -She did not use a disinfectant on the EPA List K for disinfectants effective against Clostridium difficile D. Staff interviews HS #1 was interviewed on 1/23/24 at 10:00 a.m. She said she did not know if there was anything she needed to do differently for residents who were on transmission based precautions with Clostridium difficile. She said she wore gloves for all residents' rooms that she cleaned but did not know if she needed to wear a gown for residents on isolation. She said she used Oxivir to clean residents' rooms and it needed to be visibly wet for one minute. HS #1 said she did not know if there were any other disinfectants she needed to use for Clostridium difficile. She said surfaces needed to be cleaned from clean to dirty and after cleaning a dirty area she should not return to a clean area. The director of nursing (DON) who was also the facility's infection preventionist (IP) was interviewed on 1/23/24 at 10:36. She said when a resident who was on transmission based precautions for Clostridium difficile was discharged they did a full deep cleaning of the room. She said the room should be cleaned with the Clorox Healthcare Fuzion Cleaner because it was an approved disinfectant for Clostridium difficile. The DON said surfaces should remain visibly wet for the manufacturer recommended time of two minutes. She said housekeepers should wear gowns and gloves to clean rooms with Clostridium difficile. She said it was important to start from clean to dirty and top to bottom to not track dirty particles back to clean areas as it could potentially spread infectious agents.

Based on observation, record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#196) of five residents reviewed for medication errors of 30 sample residents. Specifically, the facility failed to ensure that Resident #196 was administered an anticoagulant medication correctly by removing the medication from a capsule before administration to the resident. Findings include: I. Professional reference Boehringer Ingelheim Pharmaceutical. (November 2023). Package insert. Pradaxa. U. S. Food and Drug Administration (FDA). https://content.boehringer-ingelheim.com/DAM/c669f898-0c4e-45a2-ba55-af1e011fdf63/pradaxa%20capsules-us-pi.pdf, retrieved on 1/24/24 at 10:07 a.m. Pradaxa capsules should be swallowed whole. Pradaxa capsules should be taken with a full glass of water. Breaking, chewing, or emptying the contents of the capsule can result in increased exposure (more of the drug in a shorter amount of time). Amaraneni, A., Chippa, V., and [NAME], A. (2023). Anticoagulation Safety. Stat Pearls. National Library of Medicine. https://pubmed.ncbi.nlm.nih.gov/30085567/#:~:text=Oral%20anticoagulants%20have%20been%20classified,for%20harm%20when%20used%20clinically, retrieved 1/25/24 at 11:38 a.m. Oral anticoagulants have been classified as high alert medications according to the Institute of Safe Medication Practices (ISMP) because they have the potential for harm when used clinically. II. Facility policy and procedure The Therapeutic Research Center Medications That Should Not Be Crushed reference guide, revised February 2023, was provided by the director of nursing (DON) on 1/22/24 at 10:05 a.m. It revealed in pertinent part, Pradaxa (Dabigatran) intact product must be taken to avoid increased exposure. III. Resident #196 A. Resident status Resident #196, age 93, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included periprosthetic right hip fracture and atrial fibrillation (abnormal heart rhythm). The minimum data set assessment (MDS) was not completed due to the resident being recently admitted . According to the 1/22/24 nursing assessment the resident was alert to person, place and time. The nursing assessment revealed the resident had swallowing difficulties, was on a modified diet and required crushed medications to be administered. B. Observations On 1/22/24 at 7:14 a.m. certified nurse aide with medication authority (CNA/MA) #1 opened the Pradaxa capsule and sprinkled the medication into applesauce. CNA/MA #1 entered Resident #196's room and administered the medication to the resident. -CNA/MA #1 did not verify or obtain guidance if medication was able to be removed from the capsule from reference material or licensed nursing staff prior to the administration of the medication. C. Record review The 1/21/24 computerized physician order (CPO) revealed an order for Pradaxa (an anticoagulant medication) oral capsule 150 milligrams (mg). Give by mouth two times a day for atrial fibrillation. The 1/21/24 CPO revealed an order for anticoagulant bleeding monitoring including blood tinged or frank blood in urine, black tarry (sticky) or frank blood in stool, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status or significant or sudden change in vital signs every shift. -A comprehensive review of the CPO did not reveal Pradaxa could be removed from the capsule for administration. IV. Staff interviews CNA/MA #1 was interviewed on 1/22/24 at 10:00 a.m. She said Resident #196 required his medications to be crushed because of a swallowing problem. She said she did not know if medication could be removed from the capsule. She said she had not thought to check to see if the medication could be removed from the capsule. She said medications that could not be crushed or removed from the capsule should be verified with the licensed nursing staff. The DON was interviewed on 1/22/24 at 10:18 a.m. She said, upon consultation with the facility pharmacist, Pradaxa should not be removed from the capsule because the capsule was removed from the drug, more of the drug could be absorbed in a shorter amount of time which increased the risk of bleeding. She said Resident #196 would be monitored for bleeding but the physician provider did not want additional monitoring (blood work) at this time. She said the provider had changed Pradaxa to Eliquis (an anticoagulant), which could be crushed. She said, in consultation with the pharmacist, she had provided a list of updated medications that should not be crushed reference guide for the medication administration carts. She said staff that provided medication administration should reference this guide before crushing or removing medications from their capsules. She said the CNA/MA's should verify with their licensed nursing partners before crushing medications. She said if there were additional concerns by nursing staff the pharmacy should be consulted. The pharmacist was interviewed on 1/23/24 at 12:48 p.m. She said Pradaxa should not be removed from its capsule because of the increased risk of rapid absorption of the drug which increased the risk of bleeding. She said Resident #196 had only received two doses of Pradaxa since admission the risk of bleeding was not as high of a concern and did not require lab work. She said the provider had changed Resident #196 to an anticoagulant which could be crushed. She said she had provided nursing staff with education and reference materials for which medications could be crushed or removed from their capsules.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services and assistance for bathing for two (#108 and #96) of four sample residents reviewed out of 30 sample residents. Specifically, the facility failed to provide bathing for Resident #108 and #96 to maintain personal hygiene. Findings include: I. Facility policy and procedure The Activity of Daily Living policy, dated October 2023, was provided by the nursing home administrator (NHA) on 1/23/24/at 10:50 a.m. It read in pertinent part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support to maintain. ADL documentation will be maintained in the electronic health record under tasks, care plan, assessments, or therapy documentation. ADL's will be care planned to reflect the resident specific needs. II. Resident #108 A. Resident status Resident #108, age 79, was admitted on [DATE] and discharged on [DATE]. According to the January 2024 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), multiple fractures of pelvis (sacrum, and pubis), type 2 diabetes mellitus and chronic kidney disease. The 1/4/23 minimum data set (MDS) assessment was in progress. The 1/11/23 interdisciplinary (IDT) brief interview for mental status (BIMS) assessment revealed the resident had moderate cognitive impairment with a BIMS score of 11 out of 15. The 1/5/23 functional performance observation assessment revealed he required substantial/maximal assistance with one person for eating, toileting, personal hygiene, transfers and bed mobility. He was dependent for sit to stand. Shower/bathing was not assessed. B. Resident interview and observation Resident #108 was interviewed along with the resident's representative on 1/17/24 at 3:05 p.m. Resident #108's hair was disheveled and long, uncombed and greasy. The resident's representative said she complained to the facility about his lack of showers and hygiene because he had been there for two weeks before the staff finally gave him a sponge bath. Resident #108 said he wanted a shower at least two to three times per week. C. Record review Resident #108's ADL self care performance deficit care plan, revised 1/8/24, revealed the resident had self care performance deficits related to showers/bathing. Pertinent interventions were to assist with his bathing on Monday and Thursday evenings and as necessary or requested. The shower preference sheet dated 1/4/24 revealed the resident preferred a shower three days per week. The Kardex (a tool utilized by staff to provide consistent care for residents) report, dated 1/4/24, revealed the resident needed assistance with his bathing on Monday and Thursday evenings and as necessary or requested. Resident #108's bathing task records were reviewed from 1/4/24 to 1/17/24. The records revealed the resident was scheduled for two showers per week on Tuesday and Friday day shifts, per patient preference. Resident #108 was documented in the electronic health record (EHR) to have received no showers from 1/4/24 to his discharge on 1/17/24. The resident was documented to have refused bathing on 1/8/24 and 1/12/24 and one sponge bath on 1/16/24. -However, there was no documentation in the progress notes or CNA task records why the resident refused or documentation of assessment or follow up. -The resident missed all of his scheduled showers. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 1/18/24 at 3:00 p.m. She said she had worked at the facility for about one year and the staff mainly did showers, not bed baths, at the facility. CNA #3 said she documented the showers in the EHR, including the type of shower and any resident refusals. CNA #3 said the process for resident refusals was to document in the EHR and she would put in a comment about why the resident refused. CNA #3 said she asked the resident three times and then documented the refusal and put it in the note. CNA #3 said she was not required to tell the nurse about the refusal since she added a comment in the task section. Licensed practical nurse (LPN) #2 was interviewed on 1/18/24 at 03:07 p.m. She said the CNAs completed the showers and sometimes occupational therapy (OT) worked on that as part of therapy. LPN #2 said the CNAs documented in the EHR task section. LPN #2 said the CNAs let the nurses know of shower refusals and how many refusals because they should try a couple of times to get the resident to take a shower. LPN #2 said the CNAs needed to let the nurses know if a resident was not getting showers because of infection control concerns. LPN #2 said it was important for the residents to receive regular showers for good hygiene, cleanliness, to feel good, promote healing and infection control especially for those who were post surgical residents. The director of nursing (DON) was interviewed on 1/22/24 at 3:33 p.m. She said the CNAs completed the showers and if OT did the showers she asked the CNAs to chart that. The DON said on admission the residents were asked about their shower preferences and she noted that Resident #108's preference was for three times per week. The DON said she would recommend a minimum of two showers per week for basic hygiene and cleanliness. The DON said if a resident refused a shower she would expect the CNA to tell the nurse so they could help encourage the resident and chart that in the progress notes. The DON said it was important for Resident #108 to receive his showers per his preference in addition to maintaining his dignity and cleanliness. 47150 III. Resident #96 A. Resident status Resident #96, age greater than 65, was admitted on [DATE] and discharged on [DATE]. According to the February 2023 CPO, diagnoses included major depressive disorder, anxiety disorder, fracture of the upper and lower end of right fibula, muscle weakness, moderate obesity and presence of an artificial knee joint. The 1/8/23 MDS assessment revealed the resident was cognitively intact with a BIM) score of 15 out of 15. The resident required supervision with oral hygiene, dependent with bed mobility, toileting, and maximal assistance with personal hygiene which included showers. He had no behaviors or refusals of care. B. Record review Resident #96's comprehensive care plan, initiated on 1/2/2023, identified the resident had an ADL self-care performance deficit related to toe-touch weight bearing (TTWB), open reduction and internal fixation (ORIF) of the left ankle. Interventions included one to two staff assistance with personal hygiene including showers. -The Kardex did not indicate shower days for Resident #96. The bathing record from 1/1/23 to 2/24/23 revealed the resident received one shower in a 55 day time frame. Documentation showed that the facility charted his showers as not applicable for 46 days from 1/4/23 to 2/24/23. Eight days were documented as the resident wasunavailable. C. Staff interviews CNA #2 was interviewed on 1/22/24 at approximately 2:00 p.m. The CNA said the resident's showers were assigned each day. She said each resident's shower days were assigned per the resident's preference. She said each CNA verified from the EHR who their assigned showers were in order to plan accordingly. The CNA said all refusals were reported to the unit nurse. CNA #2 said residents who were not bathed regularly could be at risk for infections, itchiness, and dry skin. Registered nurse (RN) #1 was interviewed on 1/22/24 at 2:10 p.m. The RN said the CNAs completed showers during their shift and reported all refusals to the nurse. The RN said the nurses usually attempted to find out the reason for the refusal and provided education to the resident about the importance of regular showers. The RN said regular showers were important to avoid the spread of infectious diseases.

Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to: -Clean glucometers between residents; and, -Properly don and doff personal protective equipment (PPE) for isolation rooms. Findings include: I. Facility policy and procedure The Fingerstick Blood Sugar/[CONDITION(S)]/[CONDITION(S)] policy, dated July 2022, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m. read in pertinent part, procedure 1. gather equipment; glucose monitor, test strips, lancet, gloves, and germicidal disposable wipes. 2. Wipe down blood glucose monitor with approved germicidal wipes 3.explain procedure to resident 4. Provide privacy 5. wash hands 6. apply gloves 7. Wipe residents' fingers with alcohol wipe, allow air dry, do not blow on area 8. obtain finger stick blood sugar level 9. Discard lancet in sharps container 10 wipe down blood glucose monitor with approved germicidal wipes. 11. Wash hands. 12. Document blood glucose in electronic medical records. The Infection Control Prevention and Control Program policy, dated September 2017, received from the the nursing home administrator (NHA) on 10/10/22 read in pertinent part, the infection prevention and control program is a facility wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. Goal is to decrease the risk of infection to residents and personnel. Ensure compliance with state and federal regulations relating to infection control. II. Glucose monitor A. Observations On 10/11/22 at 3:39 p.m. licensed practical nurse (LPN) #1 was observed using a glucose monitor on a resident. She used the same glucose monitor on another resident without disinfecting between the residents. B. Staff interviews LPN #1 was interviewed on 10/11/22 at 4:05 p.m. She said there was one glucose monitor per cart and if a resident was in isolation they had their own in their room. She said glucose monitors should be cleaned between residents for infection control measures with wipes and allowed to air dry. She confirmed she did not clean the glucose monitor between residents. The DON was interviewed on 10/11/22 at 4:07 p.m. after she was notified of the glucose monitor not being sanitized between patients. She said they have one glucose monitor for each resident requiring glucose monitoring in their rooms. She said nurses were to be cleaning glucose monitors with sani cloth purple top wipes between uses if the monitor was used on multiple residents. She said staff were to follow the recommendations on the back of the sani wipes for dry time, she said it was between two to four minutes. She said she would start education on disinfecting glucose monitors immediately. C. Additional information On 10/12/22 at 8:42 a.m. the DON provided a blood glucose monitor audit performed on 10/11/22 showing all residents in the facility had their own glucose monitor in their room. A one-to-one education was completed with LPN #1 revealing each resident had their own glucose monitor in their room and glucometers were to be disinfected between use. An all staff inservice attendance record for glucometer checks indicating one glucose monitor per resident and the need to be disinfected between uses. III. Donning and doffing PPE A. 500 unit 1. Observations On 10/12/22 observations were made on the East unit between 11:05 a.m. and 12:00 p.m. At 11:05 a.m LPN #2 was observed entering room [ROOM NUMBER]. The sign on the door read isolation precautions. She was wearing a surgical mask and goggles. She sanitized her hands, put a blue gown on, took off her surgical mask and put it into the front pocket of her scrubs. She put on a N95 mask, gloves, and entered the room. At 11:10 a.m. she exited the room wearing goggles and N95. She closed the door behind herself with a napkin, approached the trash bin, opened the lid of the trash with her hand, threw away the N95 mask, closed the trash lid, reached into her pocket for a surgical mask, and put it on. She did not sanitize her hands after she touched the lid and she did not replace her surgical mask with a new one. At 11:48 a.m. certified nurse aide (CNA) #3 was observed entering room [ROOM NUMBER]. The sign on the door read isolation precautions. CNA #3 put on a blue gown, she was already wearing a surgical mask and goggles. She put gloves on and positioned a new N95 mask on top of her surgical mask. She walked to the trash, opened the lid with her hand, threw away a plastic wrap from N95 mask, and closed the lid. She did not change her gloves, she grabbed a meal tray that was handed to her by another staff member and entered the room. She exited the room at 11:50 a.m. she was wearing a surgical mask and goggles. At 11:53 a.m. same CNA #3 was observed entering room [ROOM NUMBER]. The sign on the door read isolation precautions. CNA #3 put the blue gown on, approached the trash bin, opened the lid with her hands, threw away plastic wrap from the gown, and closed the trash lid. She did not sanitize her hands, she opened a new N95 mask, placed it on top of the surgical mask that was already on her face, put gloves on, and entered the room. 2. Staff interviews The director of nursing (DON) was interviewed on 10/13/22 around 4:30 p.m. She said residents on 500 unit were on isolation precautions for incomplete vaccination status. She said the precautions were airborne. For the airborne precautions staff were expected to wear N95 masks, goggles, gowns and gloves. After the use, masks, gloves and gowns should have been disposed of and goggles must be cleaned. She said N95 should not be worn above the surgical mask. She said she would provide education to the staff on proper PPE donning and make sure donning stations were equipped with proper trash bins and disinfecting wipes for goggles. B. 600 unit 1. Observations On 10/12/22 at 9:40 a.m. CNA #5 entered an isolation room without gowning up, applying gloves, or changing out her mask. On 10/12/22 at 12:45 p.m. the social service director (SSD) was donning a gown to enter an isolation room and walked down the hall in the gown and gloves to throw away trash touching the trash receptacle with gloves. The SSD did not change gloves prior to entering the residents room. 2. Staff interviews CNA #5 was interviewed on 10/12/22 at 9:50 a.m. She said she was returning a resident back to his room who was in isolation. She said she did not apply a gown so she could get a resident into their room timely.

Based on record review and interviews the facility failed to ensure residents had the right to formulate advance directives for four (#140, #137, #141, and #188) out of seven residents reviewed for advance directives out of 21 sample residents. Specifically, the facility failed to ensure: -Medical orders for scope and treatment (MOST) forms, used to summarize and consolidate important information about an individual's preferences for life-sustaining treatments including: cardiopulmonary recussications (CPR), artificial nutrition, and hydration, were completed accurately and thoroughly, for Residents #140, #137, #141, and #188; -That when an individual other than the resident signed and completed the resident's MOST form that resident representative had the legal authority to do so, for Residents #140, #137, #141 and #188; and, -The facility obtained documentation proof that the resident representative signing the resident's MOST form had the legal authority to make medical decisions on behalf of the resident, for Residents #140, #137, #141, and #188. Findings include: I. Professional reference The Colorado Advance Directives Consortium, Guidance for Health Care Professionals website, dated [DATE], retrieved on [DATE] from http://www.coloradoadvancedirectives.com/wp-content/uploads/[DATE]-MOST-Booklet-REV-2015.pdf read in pertinent part, If the individual resides in a nursing facility, the facility staff are responsible for keeping the MOST form updated. The MOST must be signed by the individual or, if incapacitated, by the individual's authorized healthcare agent (a surrogate: a designated individual legally empowered to make decisions related to the health care of an individual in the event that he or she is unable to do so; also known as agent and proxy), proxy, or guardian. It must also be signed by a physician, advanced practice nurse, or physician's assistant. This signature translates patient preferences into medical orders, which must be followed regardless of the provider's privileges at the admitting facility. The Colorado Revised Statutes Title 15- Probate, Trusts, and Fiduciaries Article 18.5- Proxy and Surrogate Decision Makers for Medical Treatment and for the Health Care Benefit Decisions revised 2020, retrieved [DATE] from https://leg.colorado.gov/sites/default/files/images/olls/crs2020-title-15.pdfread in pertinent part, A power of attorney must be signed by the principal. The power of attorney must contain a date of execution. A health care provider or health care facility may rely, in good faith, upon the medical treatment decision of a proxy decision-maker if an adult patient's attending physician determines that such patient lacks the decisional capacity to provide informed consent to or refusal of medical treatment and no guardian with medical decision-making authority, agent appointed in a medical durable power of attorney, person with the right to act as a proxy decision-maker was appointed. The determination that an adult patient lacks decisional capacity to provide informed consent to or refusal of medical treatment may be made by a court or the attending physician, and the determination shall be documented in such patient's medical record. The attending physician has obtained an independent determination of the patient's lack of decisional capacity by another physician; by an advanced practice nurse who has collaborated about the patient with a licensed physician either in person, by telephone, or electronically; or by a court. II. Facility policy and procedure On [DATE] at 12:42 p.m., a request was made to the nursing home administrator for the facility's policy and procedures on MOST forms, advanced directive, resident rights, and quality of care; these policies were not provided. III. Resident #140 A. Resident status Resident #140, age 91, was admitted to the facility on [DATE]. According to the [DATE] computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment was not completed for BIMS at the time of the survey. A brief interview for mental status (BIMS) evaluation was completed on [DATE]; the resident scored four out of 15 indicating severe cognitive impairment. B. Record review The resident's admission record/face sheet revealed the resident was her own responsible party and documented that the resident's daughter was her emergency contact. -The face sheet did not identify a resident representative with medical power of authority (MPOA) decision making authority. Review of Resident #140's MOST form dated [DATE], revealed the form was signed by an individual identified as the resident's son. -The resident's medical record failed to show documented proof that the resident's son was her legally designated MDPOA for medical decisions. C. Interviews Resident #140 was interviewed on [DATE] at 10:40 a.m. The resident was unable to answer questions about medical concerns or medical decisions. The resident's family member was interviewed on [DATE] at 11:02 a.m. The resident's family member said the resident's daughter was responsible for making medical decisions for the resident; however, the facility permitted the resident's son-in-law to sign the resident's MOST form. III. Resident #137 A. Resident status Resident #137, age 91, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment had not been completed including the BIMS evaluation at the time of the survey. B. Record review The resident's admission record/face sheet identified the resident as her own responsible party and her son as the medical consent contact. Review of Resident #137's MOST form, dated [DATE], revealed the resident's identifying information, including the resident's name, was left blank. -The form was incomplete and a medical professional reviewing the form would have no way to link the form to the Resident #137. -The resident's medical record failed to show legal paperwork in the resident's record that someone other than the resident was legally appointed to make medical decisions for the resident. C. Interviews Resident #137 was interviewed on [DATE] at 10:56 a.m. The resident was unable to answer questions about health care [NAME]. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 11:23 a.m. LPN #2 said the resident's MPOA paperwork was in the resident's medical record behind the resident's MOST form; when the LPN looked in the resident's chart the MPOA paperwork was missing. The LPN said the resident's medical record should contain a copy of the resident's MPOA appointment if another person was going to make medical decisions on behalf of the resident. LPN #2 said the social services director's (SSD) responsibility to collect the MDPOA documents from the resident's legal representative. D. Additional information -When alerted that the resident name was missing from the resident's MOST form the facility completed the resident identification information on the MOST form to identify the resident's name and date of birth. On [DATE] at 3:20 p.m. the NHA provided the resident's MPOA document. The form revealed the resident's son was appointed to be the resident's legal representative for medical decisions. However, the form was not signed by the resident; It was instead signed by the person appointed to be as the resident's MPOA. The signature on the form, that should have been the resident's signature as the person giving a chosen person the authority to speak on their behalf, was legible and the signature of the resident's son and not the resident. IV. Resident #141 A. Resident status Resident #141, age 85, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment had not been completed including the BIMS evaluation at the time of the survey. . B. Record review The resident's admission record/face sheet identified the resident as her own responsible party and her daughter as emergency contact; there was no person identified as the resident's MPOA. Review of Resident #141's MOST form for advance directives, dated [DATE], revealed the form was not signed by the resident, but instead was signed by the resident's daughter. -The resident's medical record failed to show legal paperwork in the resident's record that someone other than the resident was legally appointed to make medical decisions for the resident. C. Interviews Resident #141 was interviewed on [DATE] at 10:02 a.m. The resident was able to talk about meals and the therapy she was receiving but could not explain where she was or why she was at the facility. V. Resident #188 A. Resident status Resident #188, age 75, was admitted to the facility on [DATE]. According to the [DATE] CPO, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] MDS assessment had not been completed including the BIMS evaluation at the time of the survey. B. Record review The resident's admission record/face sheet documented the resident was her own responsible party, the resident's spouse was the emergency contact, and no person was identified as the resident's MPOA. Resident #188's MOST form, dated [DATE], was signed by a person identifying as the resident's medical durable power of attorney (MDPOA). -However, the facility did not have documented proof that the individual signing the resident MOST was designated to be the resident's MDPOA. -The resident's medical record failed to show legal paperwork in the resident's record that someone other than the resident was legally appointed to make medical decisions for the resident. C. Interviews Resident #188 was interviewed on [DATE] at 1:12 p.m. The resident was unable to accurately state what day of the week, remember what she had for lunch or discuss medical details. RN #1 was interviewed on [DATE] at 11:35 a.m. RN #1 said that a resident's MDPOA paperwork should be in the resident's medical record paper chart under the social services section. The nurse would be responsible for collecting that paperwork from the families. RN #1 was unable to locate the resident's MDPOA paperwork. VI. Additional staff interviews The director of nursing (DON) was interviewed on [DATE] at 10:40 a.m. The DON said during the admission process, the admitting nurse was tasked with reviewing the MOST form with the resident. If the resident was undecided, then the nurse educated them that they were a full code, until the resident decided otherwise. The interdisciplinary team (IDT) completed a chart audit within ,d+[DATE] hours to ensure that all documentation was present. The social services director (SSD) collected the responsible party documents, power of attorney or health care proxy, from families and scanned the paperwork into the resident's chart. If a resident was not alert and oriented, the nurse reached out to the responsible party listed on the admission record to help with signing paperwork and making decisions for the resident. The DON was not aware of the process the facility used to ensure that the responsible party listed on the admission record had valid paperwork in the chart to make medical decisions on behalf of the resident. The SSD was interviewed on [DATE] at 12:49 p.m. with a nursing home administrator present (NHA). The SSD said she was not part of the process for ensuring that MOST forms were signed or audited. The SSD said she was part of the process for making sure that the family brought their POA paperwork in by the time of the first care conference which was within a week of admission. The SSD said the admitting nurse would request the family to bring in the paperwork if they were the ones filing out the admission paperwork. The SSD said that the medical records manager did the audits for the POA paperwork. The NHA was interviewed on [DATE] at 3:14 p.m. The NHA said the medical records department did the chart audits for new admissions but they did not have an audit form to show an audit has been completed. The medical records department communicated what was missing to the departments through an internal text system and email. The NHA said that during the survey, the IDT team had identified that they did not have an audit tool and there were gaps in their process of ensuring documentation was in the resident's charts. The NHA said the facility would develop a performance improvement plan (PIP) to address the missing POA forms and create an audit tool to check for complete admission records. The NHA said the facility did not have POA paperwork in the records for Residents #140, #141, or #188. The facility did have a medical durable power of attorney (MDPOA) document for Resident #137 that the NHA was able to locate in a different file outside of the resident's medical record. The NHA showed the MDPOA during the interview and the document had a date of execution at the bottom but the year was cut off in the copy. The NHA stated that the facility was going by the fax transmittal date on the top of the form, not the date of execution at the bottom. The regional clinician resource (RCR) was interviewed on [DATE] at 4:05 p.m. with DON and the NHA present in regards to the new nursing admission checklist the facility had created during the survey for their PIP. She said the form would be used by IDT within 24 hours of a resident's admission. Under the consent section of the form, there was a section to indicate the MOST form had been completed. There was also a section to indicate that the POA/Proxy had been completed. The RCR, DON, NHA acknowledged that there was not a section on the checklist that pertained to ensuring that the responsible party paperwork was in the resident's chart. VII. Facility follow-up On [DATE] at 11:53 p.m. the regional clinical resource (RCR) provided an inservice for facility staff on the details of the MOST forms. Four staff were in attendance; the DON and three LPNs. The training curriculum included a brief overview of the medical orders for scope of treatment (MOST)- guidance for healthcare professionals dated [DATE] and revised 2017, provided by The Colorado Advance Directives Consortium. That guidance document presented to nursing staff read in pertinent part: Only valid surrogate decision makers (Medical Durable Power of Attorney, Guardian, Proxy-by-Statute, etc.) have authority to sign the MOST form; family members, financial powers of attorney, or other persons who are not valid healthcare decision makers do not have authority to sign. If there is no signature by the individual or his or her surrogate decision maker, the form is not valid as orders or patient preferences. Healthcare Proxy-by-Statue: In Colorado, no one is given automatic authority in decision making for another adult. Next of kin' , spouse, adult children, or other relatives are not authorized decision makers unless duly appointed as a Healthcare Agent or Guardian. Medical Durable Power of Attorney: In Colorado, no one is automatically authorized to make healthcare decisions for another adult. The Medical Durable Power of Attorney (also called the 'Power of Attorney for Healthcare') is a document the individual (the principal) signed to appoint someone else to make the principal's healthcare decisions in case of incapacity. Additional guidance included in the nurses training revealed nursing staff were to: -Completed a MOST form with all new residents on the day of admission; and, -Obtain the resident's signature on the form. On [DATE] at approximately 4:00 p.m., the NHA provided documentation that the facility conducted a full audit of resident charts to ensure completed MOST form. The facility planned to contact resident representatives where MOST forms were incomplete or the resident record was missing documentation of MDPOA.

Based on record review and staff interviews, the facility failed to ensure one (#191) resident reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 21 sample residents. Specifically, the facility failed to have a wound care order in place prior to treatment being provided for Resident #191. Findings include: I. Facility policy and procedure The Pressure Ulcer Skin Monitoring and Management policy, dated October 2021, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m. In pertinent part read, a resident having a pressure ulcer receives necessary treatment and services to promote healing, prevent infection and prevent new avoidable sores from developing. The nurse is responsible for assessing and evaluating the residents wounds on admission, readmission, weekly and discharge. Prevent existing pressure ulcers from worsening, nursing staff to implement the following approaches as appropriate and consistent with care plan; referral to wound physician, pressure reduction measures, registered dietician and supplements as indicated, therapy as indicated to increase mobility. Nurse to administer treatment to each affected area per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] II. Resident status Resident #191, age 86, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/2/22 brief interview for mental status score (BIMS) revealed the resident had a moderate cognitive impairment with a status score of 11 out of 15. Based on nurse assessment, it documented he required one person extensive assistance with transfers, toileting, dressing, bed mobility and personal hygiene. III. Wound care observations On 10/12/22 at 9:53 a.m. registered nurse (RN) #1 cleaned the resident's right heel with saline and gauze. He applied a bandage with [MEDICATION(S)] (a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/13/22 at 11:05 a.m. RN #2 observed the residents right heel, it had dressing covering it with nurse initials and date of 10/13/22. IV. Record review The October 2022 CPO reviewed on 10/12/22 at 10:01 a.m. failed to reveal a wound care order for the resident's right heel. The admission skin assessment dated [DATE] revealed the resident was admitted with two deep tissue injuries (DTI, a type of pressure injury) one to each heel. The October 2022 CPO reviewed again on 10/13/22 at 11:44 a.m. (after the wound observations, see above) revealed a new order for resident's right heel DTI: [MEDICATION(S)] and foam dressing daily every day shift for stage two, ordered on 10/13/22 at 11:22 a.m. V. Staff interviews RN #1 was interviewed on 10/12/22 at 10:19 a.m. He said the resident had a DTI to his right heel. He said he cleansed the wound with saline and gauze, applied [MEDICATION(S)] to a bandage then applied it and secured with self adhesive wrap to keep dressing in place. He said [MEDICATION(S)] was commonly used for wounds. RN was unable to locate the order for dressing applied to the right heel in the resident's CPOs. He said there should be an order in place for wound care. RN #2 was interviewed on 10/13/22 at 11:10 a.m. She said the resident had wounds to both heels and she applied dressings this morning. The RN pulled up an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she applied this dressing order to the right heel because that treatment should be for the right heel and not the left. She said she would get the order clarified. The DON was interviewed on 10/13/22 at 1:45 p.m. She said there needs to be a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said nurses needed an order so they knew what to do for wounds including supplies they needed. She said the nurses needed to ensure that the order was appropriate for the wound.

Based on record review and interviews, the facility failed to ensure one of five residents (#197) reviewed for respiratory services out of 21 sample residents, received respiratory care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: I. Facility policy and procedure The Oxygen Administration policy, dated July 2022, received from the director of nursing (DON) on 10/13/22 at 3:50 p.m., documented in pertinent part, oxygen therapy is administered, as ordered by the physician. Procedure includes obtaining a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] II. Resident status Resident #197, age 92, was admitted on [DATE]. According to the October 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 10/6/22 brief interview for a mental status score (BIMS) assessment revealed the resident was severely cognitively impaired with a brief interview for a mental status score (BIMS) of five out of 15. According to the resident's care plan, he required two person assistance with transfers, bed mobility, toileting, dressing and personal hygiene. III Observations On 10/10/22 at 3:20 p.m. the resident was observed wearing a nasal cannula with oxygen at two liters per minute. IV. Record review The 10/5/22 CPO failed to reveal an order for [MEDICAL RECORD OR PHYSICIAN ORDER] The daily skilled nursing notes on 10/5/22, 10/6/22, and 10/7/22 documented the resident was receiving four liters per minute of oxygen via a nasal cannula. The 10/8/22 and 10/9/22 skilled nurses notes documented the resident was receiving oxygen at two liters per minute via nasal cannula. No skilled nursing note for 10/10/22 was located. V. Staff Interviews Registered nurse (RN) #3 was interviewed on 10/11/22 at 12:48 p.m. She said the resident was on oxygen. The RN was unable to find an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said there should be orders for oxygen. Certified nurse aide (CNA) #1 was interviewed on 10/11/22 at 12:55 p.m. She said Resident #197 was on oxygen. RN #4 was interviewed over the phone on 10/13/22 at 1:35 p.m. He said the resident was on four liters of oxygen via nasal cannula when he was working with the resident. The DON was interviewed on 10/13/22 at 1:45 p.m. She said every resident should have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on record review and interviews, the facility failed to ensure the residents were kept free from significant medication errors for one (#1) out of three sample residents. Specifically, the facility failed to ensure a licensed practical nurse (LPN #1) correctly transcribed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN administered the 2.5 mg of [MEDICATION(S)] to Resident #1 on 6/23/22, and registered nurse (RN) #1 administered the 2.5 mg of [MEDICATION(S)] as well as the 30 mg/ml [MEDICATION(S)] on the morning of 6/24/22. On 6/25/22 the resident had altered mental status (according to the nursing progress notes) and was transported to a local hospital. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 8/1/22 to 8/2/22, resulting in the deficiency being cited as past noncompliance with a correction date of 7/20/22, as the facility had reviewed the medication error plan of correction with the pharmacist and medical director, and had completed all staff education. I. Facility policy and procedure The Medication Errors and Adverse Reactions policy and procedure, revised August 2021, was provided by the director of nursing (DON) on 8/2/22 at 12:00 p.m. It read in pertinent part: Adverse drug reactions and medication errors with adverse clinical consequences must be reported to the resident's attending physician immediately. Nursing services must immediately implement and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . II. Resident #1 A. Resident status Resident #1, age 87, was admitted to the facility on [DATE] and discharged to hospital 6/25/22. According to the June 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/25/22 minimum data set (MDS) assessment revealed the resident had short term memory problems, and her cognitive skills for daily decision making were modified independence (some difficulty in new situations only). She required extensive assistance of one staff member with mobility and activities of daily living (ADLs). She did not have any behaviors or rejections of care. B. Record review A review of the resident's June 2022 physician discharge orders from the hospital revealed the following orders: -[MEDICATION(S)] 30 mg/0.3 ml (milligram per milliliter) Inject 30 mg just under the skin every 24 hours for three days, ordered 6/23/22 with a start date of 6/23/22. -[MEDICATION(S)] 2.5 mg (miligram) tablet by mouth in the morning and 1 tablet before bedtime, ordered 6/23/22 with a start date of 6/26/22. A review of the June MAR (medication administration record) revealed the following: -6/23/22 it was documented the resident had been given [MEDICATION(S)] 2.5 mg at 7:00 p.m. -6/24/22 it was documented the resident had been given [MEDICATION(S)] 2.5 mg at 7:00 a.m. -6/24/22 it was documented the resident had been given [MEDICATION(S)] 30 mg/0.3 ml at 7:00 a.m. A review of the resident's progress notes revealed the following physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] Changed: hold [MEDICATION(S)] until 6/27. A review of the resident's electronic medical record revealed no additional documentation regarding the medication error on 6/24/22 when Resident #1 was given both the [MEDICATION(S)] and [MEDICATION(S)] at 7:00 a.m. A 6/25/22 nursing progress note documented the following: Change of condition: AMS (altered mental status). Resident sent out to (name of hospital) due to change in condition. Family, MD (medical doctor) and DON (director of nursing) notified. A review of the hospital records from 6/25/22 revealed the following progress note: CT (computed tomography scan) head reveals new 12 mm (millimeter) acute right cerebral convexity (aspect of the cerebral hemisphere that lies in contact with the flat bones of the skull) subdural hemorrhage and trace increased falcine and tentorial (location over the entire convexity of the brain) hemorrhage. C. Facility investigation On 6/24/22 the facility began an investigation of the incident immediately upon learning of the medication error. The investigation revealed the following: Wrong medication was given; order was (to) continue [MEDICATION(S)] until 6/26(22) and then start [MEDICATION(S)] ([MEDICATION(S)]). Pt (patient) was given the [MEDICATION(S)] and [MEDICATION(S)] this AM. MD (medical doctor) made aware, monitor for bleeding, DON (director of nursing) made aware, and order has been updated. The facility investigation determined LPN #1 had entered the hospital discharge orders incorrectly. The LPN had both the [MEDICATION(S)] and [MEDICATION(S)] starting on the same date (6/23/22) when the [MEDICATION(S)] should have been started on 6/26/22, after the [MEDICATION(S)] had been discontinued. III. Facility actions The facility took action immediately after the medication error to identify any other potential areas of concern and prevent any recurrence. On 6/25/22 upon identification of the error, LPN #1 was provided education by the director of nursing (DON) regarding correctly entering physician orders, and verification of the hospital discharge orders. Each nurse working in the facility was provided verbal education starting on 6/25/22. The DON provided education to all nursing staff covering medication administration, verification of admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility-wide audit was completed on 6/25/22 to ensure no additional physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Starting 6/25/22, the facility began auditing each new order to ensure the order had been entered correctly. On 7/20/22 the plan of correction was reviewed by the pharmacist, and the medical director. The result of the review revealed no additional medication errors had occured in the facility. IV. Interviews The DON was interviewed on 8/1/22 at 2:58 p.m. She said the facility identified the medication error the day the error occurred. The DON said as part of the investigation, they had determined the discharge orders from the hospital were not very clear and there were two separate discharge orders, although both orders had the [MEDICATION(S)] being given after the [MEDICATION(S)], and never at the same time. The DON said she had provided education to LPN #1 regarding the medication error, and that the LPN had been terminated from the facility, although due to non-related issues. The DON said the facility continues to review all new orders during the clinical team meeting to ensure medication errors do not occur. The DON said there had not been any additional medication errors since the 6/24/22 error. The DON said the facility had also hired an additional nurse whose duties included going over physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician (MD) #1 was interviewed on 8/1/22 at 3:12 p.m. He said he had been made aware of the medication error by the facility on the day it occurred. He said the order was written so that the [MEDICATION(S)] and [MEDICATION(S)] were not to be given together. The MD said those medications were not typically given together because [MEDICATION(S)] is a fast-acting blood thinner and the [MEDICATION(S)] was a long-acting blood thinner, so it would be like double treating and that could have the potential for increased bleeding. The MD said the resident was on the lowest dose of both medications, and since Resident #1 had only been given one dose, he felt monitoring for bleeding was an appropriate intervention. The MD said he had reviewed the medication list that had been verified by the physician working when Resident #1 had been admitted to the facility, and after that review it was clear the order had been written for the [MEDICATION(S)] to have a start date of 6/26/22. The pharmacist was interviewed on 8/1/22 at 4:04 p.m. She stated the facility had informed her of the medication error and she had reviewed it and had determined that the medication list from the discharging hospital had been a little confusing, but the medication list the physician had verified had been clear, and that list should have been used by the facility. The pharmacist said the [MEDICATION(S)] was to be started on 6/26/22, but had been entered into the system to start on 6/23/22. The pharmacist said the [MEDICATION(S)] was to be given for three days (6/23/22-6/25/22), but due to the error, the resident was given [MEDICATION(S)] on 6/23/22 and 6/24/22 when she should not have been given the medication until 6/26/22. The pharmacist said those medications did increase the risk for bleeding, and those medications given together would increase the risk further, but the resident was on a very small dose of both, although that did not negate the fact that there was a medication error.

Based on record review and interviews, the facility failed to ensure the medical record was complete and accurate in accordance with professional standards of practice for one (#2) of three sample residents. Specifically, the facility failed to ensure the resident record contained timely assessments for the duration of the resident stay in the facility from her admission on 3/23/22 through her discharge on 3/28/22. Findings include: I. Facility policy and procedure The Health Information Policy and Procedure Manual, undated, was provided by the director of nursing (DON) on 8/2/22 at 12:00 p.m. It read in pertinent part: Assessments: Assessments are critical to the documentation system in a clinical record. Handling omissions in documentation: at times it will be necessary to make an entry that is late (out of sequence) or provide additional documentation to supplement entries previously written. Making a late entry - best practice for late entries is 24 hours. When making late entries document as soon as possible. There is not a time limit to writing a late entry, however, the more time that passes the less reliable the entry becomes. II. Resident #1 A. Resident status Resident #2, age 84, was admitted on [DATE] and discharged on [DATE]. According to the March 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had been discharged from the facility prior to a comprehensive minimum data set (MDS) assessment being completed. B. Record review A review of Resident #2 medical record from the time of admission (3/23/22) until the date of discharge (3/28/22) revealed all of the following assessments had been completed on 4/2/22, five days after the resident had discharged from the facility: -The daily skilled nursing assessments for the following days: 3/24/22, 3/25/22, 3/26/22, 3/27/22, and 3/28/22; -The bowel and bladder assessment (completed on 4/2/22); -The functional performance evaluation (completed on 4/2/22); -The elopement/wandering evaluation (completed on 4/2/22); and, -The pain management review (completed on 4/2/22). III. Interviews The assistant director of nursing (ADON) was interviewed on 8/2/22 at 12:02 p.m. She stated that she was the staff member who had completed all of Resident #2 assessments on 4/2/22. She stated that the previous director of nursing (DON) would hand her lists of residents who were missing assessments, and the expectation she was to complete the missing assessments. The ADON said she had a vague recollection of Resident #2 at the time she completed the assessments, but it would be difficult to say they were accurate due to the fact that she was not actually assessing the resident when she had completed all of the assessments. The ADON said the resident had in fact been discharged from the facility on 3/28/22, and she had completed the assessment documentation on 4/2/22, even though the resident had been out of the facility for approximately five days. The DON was interviewed on 8/22/22 at 12:23 p.m. She said she was not the DON at the time of Resident #2 stay in the facility, and could not speak to the way the facility handled documentation at that time. The DON said it was her expectation that assessment be completed timely, and that means within 24 hours ideally. The DON said if staff were unable to complete assessments the nursing managers did offer assistance, but they too were expected to complete the assessments timely, which ideally was 24 hours or less. The DON said completing the assessment five days after discharge did not provide an accurate record, due to the fact that an assessment required actually looking and or interviewing the resident and that could not be completed if the resident was no longer in the facility.

Based on interviews and record review the facility failed to provide a complete discharge summary that included a recapitulation of the stay for three residents (#1, #2 and #3) out of six sample residents. Specifically, the facility failed to provide pertinent information: -To communicate in writing or verbally that the facility was in outbreak status for COVID-19 to three different assisted living facilities where Resident #1, #2, and #3 discharged ; and, -To communicate the facility was in outbreak status for COVID-19 to an in-home health care provider that would be providing services to Resident #1 and Resident #2 at their assisted living residences. Findings include: I. Facility policy and procedure The Admission, Transfer, and Discharge policy/procedure, dated November 2016, was provided by the nursing home administrator (NHA) via email on 12/22/21 at 12:39 a.m. It revealed in pertinent part: When the facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Information provided to the receiving provider must include a minimum of the following: D. All special instructions or precautions for ongoing care, as appropriate. F. All other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. II. Facility outbreak status The COVID-19 facility line listing form was reviewed. It documented the outbreak started on 11/22/21 and currently the facility was still in outbreak status as of 12/22/21 (exit of the survey). III. Staff interviews of assisted living facilities and in-home health care provider The communities relation director (CRD) and the director of nursing (DON) of the assisted living facility for Resident #1 was interviewed on 12/22/21 via phone at 1:00 p.m. The CRD and the DON said no one at the assisted living was made aware of the COVID-19 outbreak status of the skilled nursing facility. The CRD said This was very unfortunate that we were not informed of the situation of the outbreak of COVID-19. The executive director (ED) of the assisted living facility for Resident #2 was interviewed on 12/22/21 via phone at 1:15 p.m. She said no staff at the assisted living was told of the COVID-19 outbreak status of the facility that Resident #2 came from. She said My heart dropped to my shoes that Resident #2 came to us from a facility in outbreak status. She said no staff were told of the situation from the discharging facility. The social service director (SSD) of the assisted living facility for Resident #3 was interviewed via phone on 12/22/21 at 2:00 p.m. She said the facility did not inform their facility in writing or verbally of their COVID-19 outbreak status. She said she was the staff member who drove to the facility to pick up Resident #3 and brought him to their facility. She said when she came to get Resident #3 she was not informed of their COVID-19 outbreak status. She said she did not remember any signage warning of COVID-19 in the building. She said she noticed a staff member in the building wearing a face shield and she asked them why they were wearing a face shield. She said the staff member told her everyone was wearing face shields in the facility but they did not say why. She said seeing staff in face shields should have clued her to a possible problem but she did not ask any further questions. The account executive (AE) for the in-home health care provider was interviewed via phone on 12/22/21 at 12:52 p.m. She said the in-home health care provider was notified by the facility social services director (SSD) to provide services for Resident #1 and Resident #2 in their new assisted living residences. She said the company was not informed of the COVID-19 outbreak status of the facility in writing or verbally for Resident #1 and Resident #2. IV. Resident #1 A. Resident status: Resident #1, age 88, was admitted on [DATE], readmitted on [DATE] and discharged [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/13/21 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. He required limited assistance with bed mobility, transfers, personal hygiene, and toilet use. He required extensive assistance with dressing. B. Record review The 12/7/21 discharge paperwork was reviewed for Resident #1 and did not include information to inform the assisted living facility that the discharging facility was in COVID-19 outbreak status. V. Resident #2 A. Resident status Resident #2, age 84, was admitted on [DATE] and discharged [DATE]. According to the November 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/7/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of nine out of 15. She required supervision for bed mobility, transfers, walking in her room, eating, dressing, toilet use, and personal hygiene. B. Record review -The 12/6/21 discharge paperwork was reviewed for Resident #2 and did not include information to inform the assisted living facility that the discharging facility was in COVID-19 outbreak status. VI. Resident #3 A. Resident status Resident #3, age 85, was admitted on [DATE], readmitted on [DATE] and discharged [DATE]. According to the December 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/4/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score (BIMS) of 12 out of 15. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. B. Record review -The 12/14/21 discharge paperwork was reviewed for Resident #3 and did not include information to inform the assisted living facility that the discharging facility was in COVID-19 outbreak status. VII. Staff interviews The assistant director of nursing (ADON), who was also the infection control preventionist (IP), was interviewed on 12/20/21 at 10:00 a.m. She said the facility had COVID-19 several times in the building during the [AGE] year. She said the facility was in COVID-19 outbreak status at the time Resident #1, #2, and #3 were discharged to three different assisted living facilities. She said she did not inform the COVID-19 outbreak in the facility to the three receiving assisted living facilities. She said as far as the facility knew the residents were never directly exposed to the staff and residents who had COVID-19 in the building. She said because the facility was unaware that Resident #1, #2, and #3 had direct exposure to anyone with COVID-19 the facility did not need to inform the receiving assisted living facilities that there was a COVID-19 outbreak in the building. The director of nursing (DON) was interviewed on 12/20/21 at 1:40 p.m. She said during the month of December 2021 both staff and residents had tested positive for COVID-19. She said she did not inform any of the three receiving facilities for Resident #1, #2, and #3 that their facility was in outbreak status for COVID-19. She said since the three residents were not knowingly exposed to COVID-19 the receiving facilities were not told of the situation in their building. She said it was only appropriate to tell the assisted living facilities if the residents were exposed to COVID-19 directly. She said she could not be sure for example, if a physical therapist or any other staff member may have had contact with these residents. She said to the best of her knowledge Resident #1, #2, and #3 did not have direct exposure to COVID-19 from the staff and residents who did have COVID-19. The nursing home administrator (NHA) was interviewed on 12/22/21 at 11:00 a.m. He said he did not think it was pertinent information to tell the three assisted living facilities receiving the three residents that the facility was in outbreak status for COVID-19. He said COVID-19 was everywhere and it was not required of the facility to inform the receiving facilities. The social service director (SSD) was interviewed on 12/22/21 at 11:40 a.m. She said she did not inform any of the receiving facilities for Resident #1, #2, and #3 that their facility was in outbreak status for COVID-19. She said Resident #3 was picked up directly by a staff member of the receiving facility. She said she thought the person who picked up Resident #3 could have noticed from their signage in the building that there was COVID-19 present. She said if they wanted to know they could have asked someone. (See receiving facility interview for Resident #3 below) She said we do not have any documentation of the three receiving facilities being told of the COVID-19 outbreak status. She said if the facilities would have directly asked her then she would have told them about the COVID-19 outbreak status. She said she was not trained whether to disclose the information or not to disclose the information of the COVID-19 outbreak status in the building. She said she did not provide the facility outbreak status for COVID-19 to any of the assisted living facilities receiving Resident #1, #2, or #3. She said she set up the additional in-home health care provider for Resident #1 and Resident #2. She said she did not inform the outside home health provider for Resident #1 and #2 of the facility COVID-19 outbreak status either. VIII. Facility follow-up The facility did not provide any documentation that the receiving facilities were informed verbally or in writing that the sending facility was currently in outbreak status for COVID-19. The ADON/IP sent an email on 12/23/21 at 12:52 p.m. It revealed in pertinent part: While the Infection Control and Prevention program is an ever-evolving process as changes and updates are continuously made to ensure compliance with the most recent guidance, we have identified the following areas and processes in which we have implemented changes to ensure the highest level of compliance and would like to share the updates that we have implemented: Regarding discharges, we have already started contacting receiving facilities and families regarding positives and outbreak status verbally and are creating a new process that will be more formal going forward.

Based on record review and interview, the facility failed to test facility staff, and individuals providing services under arrangement and volunteers, for COVID-19. Specifically, the facility failed to ensure certified nurse aide (CNA) #1 was tested for COVID-19 before her shift after returning from vacation during the facility's COVID-19 outbreak. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (CDPHE), COVID-19 GUIDANCE for The Residential Care Facility (RCF) Comprehensive Mitigation Guidance, last updated 11/16/21. When one or more positive tests are identified in a resident or health care personnel (HCP) (regardless of vaccination status), the facility moves to outbreak testing and follows additional response measures outlined below. Asymptomatic health care personnel (HCP) and Residents who are fully vaccinated: Complete twice weekly lab-based PCR testing. If HCP work infrequently at the facility, they should be tested within 3 days before their shift (including day of the shift). II. Facility testing policy and procedures The Resident and Staff testing policy for COVID-19, dated December 2021, was provided by the regional nurse consultant on 12/22/21 at 12:22 p.m. It read in pertinent part, It is the policy of this facility that all residents and staff will be offered testing for COVID-19 according to most recent CDPHE and CMS (Centers for Medicare and Medicaid Services) guidelines. III. Record review The COVID-19 facility line listing form was reviewed. It documented five residents and six staff members were diagnosed with COVID-19 from 11/22/21 to 12/13/21. It documented CNA #1 was tested for COVID-19 on 12/6/21 and she was diagnosed COVID-19 positive on 12/8/21. The nursing staff schedule for December 2021 was reviewed. It documented certified nurse aide (CNA) #1 (who traveled out of the country and had a negative COVID-19 test) worked on 12/1/21 during the facility COVID-19 outbreak. -There was no documentation that the CNA was tested by the facility for COVID-19 when she returned to work on 12/1/21. It documented on 12/9/21 one staff was tested positive for COVID-19. It further documented on 12/13/21, two staff and two residents were tested positive for COVID-19. -However, the residents that tested positive subsequently to 12/6/21 were not in contact with CNA #1. IV. Staff interviews The infection preventionist (IP) was interviewed on 12/20/21 at 10:30 a.m. She said the facility was in outbreak for COVID-19 when one resident was tested positive on 11/22/21. She said she immediately started testing for all staff and residents. She said from that round of testing two residents and two staff were positive. She said when CNA #1 returned to work on 12/1/21, she was not tested . She said the CNA #1 had a negative test prior to returning into the county. She said the CNA #1 was screened and did not have any symptoms and was fully vaccinated. The regional nurse consultant (RNC) was interviewed on 12/20/21 at 11:30 a.m. She said CNA #1 returned to work on 12/1/21. She said she was screened and had no symptoms. She said the facility follows the RCF guidance for outbreak testing (see above). -However, the facility was in an outbreak status as of 11/22/21 and according to the guidance (see above), CNA #1 should have been tested . CNA #1 was interviewed on 12/20/21 at 2:00 p.m. She said she traveled out of the country and returned on 11/21/21. She said she had a negative COVID-19 test prior to boarding the plane which she provided to the facility. She said she was fully vaccinated and she did not have any symptoms upon returning to work on 12/1/21. She said she worked two shifts and was not tested in the facility. She said she was tested on [DATE] and was positive with COVID-19. She said she was sent home for 10 days and returned to work on 12/17/21. The director of nursing was interviewed on 12/20/21 at 3:00 p.m. She said the facility was in an outbreak status. She said currently there were two residents and four staff positive for COVID-19. She said CNA #1 had a negative COVID-19 test prior to returning into the country which she provided to the facility. She said the CNA #1 was not tested on [DATE] when she returned to work. She said CNA #1 was tested on [DATE] before her shift. -However, CNA #1 was tested six days after she returned to work and she was positive for COVID-19.

Based on record review and interviews, the facility failed to ensure residents are free of any significant medication errors for one (#87) of five out of 25 sample residents related to anticoagulant management. Specifically, the facility failed to ensure anticoagulant medication was administered in a timely manner for Resident #87. Resident #87 was admitted to the facility following a surgical procedure. Upon admission, the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the anticoagulant medication between 3/3/21 (admitted ) and 3/9/21, representing 12 missed doses. Although the medication was not received from the pharmacy until 3/9/21, it was recorded on the medication administration record (MAR) as given on several occasions. Serious harm was likely to occur as the resident was at greatest risk for developing a blood clot by not receiving the anticoagulant medication post surgery. The facility did not do anything or was not even aware of the extent of the error until it was brought to their attention during the recent recertification survey. Findings include: I. Findings of immediate jeopardy Resident #87 was admitted to the facility following a surgical procedure. Upon admission, the resident had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident did not receive the anticoagulant medication between 3/3/21 (admitted ) and 3/9/21, representing 12 missed doses. Although the medication was not received from the pharmacy until 3/9/21, it was recorded on the MAR as given on several occasions. Serious harm was likely to occur as the resident was at greatest risk for developing a blood clot by not receiving the anticoagulant medication post surgery. The facility did not do anything or was not even aware of the extent of the error until it was brought up during the recent recertification survey. II. Facility notice of immediate jeopardy On 7/15/21 at 10:38 a.m. the nursing home administrator (NHA) was notified of immediate jeopardy via phone. III. Facility plan to remove immediate jeopardy The facility failed to ensure anticoagulant medication was administered in a timely manner. -The immediate remedy was that all residents were audited for missed medications on 6/29/21 by the Pharmacy resource. There were no anticoagulants identified as not given or not available. -Education on medication administration and was started with all nurses on 6/29/21 and completed on 6/30/21. The education included identifying medication errors, what to do if a medication is unavailable, and why it is important. -On 6/30/21 the First Dose pharmacy emergency kit was changed and [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)] were stocked to ensure no delay if a medication was newly ordered or a resident was a new admission. [MEDICATION(S)] was not added as it is in the same pharmacological class as [MEDICATION(S)] and likely can be substituted for one dose with an order if needed (both XA inhibitors-are anticoagulants, used to both treat and prevent blood clots in veins, and prevent stroke and embolism in people with [CONDITION(S)] fibrillation) to maintain other frequently used items in the first dose machine. -On 7/12/21 the nurse management team began reviews of all admissions from the previous day to occur on business days. The review includes anticoagulation orders and medication administration review. Any issues identified in the morning review are addressed immediately. IV. Removal of immediate jeopardy On 7/15/21 at 4:43 p.m. through record review and interviews the facility's plan for removal of immediate jeopardy was accepted and the level of deficient practice remains at D, no actual harm with the potential for more than minimal harm. V. Facility policies and procedures The Medication Errors and Adverse Reactions policy, revised August 2007, was provided by the director of nursing (DON) on 6/30/21 at 11:35 a.m. The policy revealed medication errors and adverse drug reactions must be reported to the resident's attending physician. -Nursing service should monitor a resident after medication error for 72 hours if clinically indicated. -A detailed account of the incident must be recorded on an incident report. Clinically relevant information about follow-up of the resident should be recorded in the chart, including: the date and time of the incident, the kind of medication error or adverse reaction, the name of the physician, the date and time the physician was conducted, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -Documentation of the resident's condition and response to treatment must be recorded during the monitoring period. V. Resident #87 A. Resident status Resident #87, age 59, was admitted on [DATE] and discharged on [DATE]. According to the March 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/8/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident received an anticoagulant medication five times during the seven day assessment period. B. Record review physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The March 2021 Medication Administration Record (MAR), revealed the [MEDICATION(S)] medication was not administered (marked with a number 7-other see nursing note: not available) on the following dates and times: -4th at 7:00 a.m., and 7:00 p.m., -5th at 7:00 a.m., -6th at 7:00 p.m., -8th at 7:00 p.m., and -9th at 7:00 a.m. The March 2021 Medication Administration Record (MAR), revealed the [MEDICATION(S)] medication was administered (marked with a check mark) on the following date and times even though the medication was not in the facility to administer to the resident: -5th at 7:00 p.m., -6th at 7:00 a.m., -7th at 7:00 a.m., and 7:00 p.m., -8th at 7:00 p.m., and -9th at 7:00 p.m. The care plan for the use of an anticoagulant therapy ([MEDICATION(S)]) related to post surgery was initiated on 3/5/21. The goal for the resident was to be free from discomfort or adverse reactions related to the use of an anticoagulant medication. One of the interventions was to monitor and report any signs/symptoms of thromboembolism: acute onset of shortness of breath, pleuritic chest pain, cough, coughing up blood, [CONDITION(S)] and anxiety. The computerized pharmacy delivery form provided by the DON on 6/30/21 at approximately 1:00 p.m., revealed the anticoagulant [MEDICATION(S)] 15 mg was delivered to the facility on [DATE] at 11:50 a.m. This form was signed by a nursing staff member. -Cross-reference F755, failed to ensure the accurate acquiring, receiving, dispensing and administering of drugs to meet the needs of each resident. The Risk Management Form #2479 for a medication error, was provided by the clinical resource representative (CRR) on 6/30/21 at 12:00 noon. The form was completed on 6/29/21 at 5:21 p.m. This was after the survey started on 6/28/21. The form revealed the resident was not given [MEDICATION(S)] on 3/4/21 morning and evening doses, 3/5/21 morning dose, 3/8/21 evening dose and 3/9/21 morning dose. -Immediate action taken revealed the resident was on daily monitoring throughout her stay. The resident was administered [MEDICATION(S)] 15 mg from 3/9/21 evening dose through 3/23/21 without complications. The facility's Medical Director was notified and reviewed the resident's clinical record. No injuries were noted at the time of the event. -The additional notes revealed on 6/29/21 the resident's chart had already closed after 30 days. The medication error was noted and the medical director was notified. He reviewed the resident's clinical record and indicated there was no negative outcome. Staff noting that the medication was not available received one-on-one education. The facility's nursing staff were provided general in-service on medication availability. A follow up call to the resident was conducted to let her know that she did not receive her medication as ordered and she said she was aware of this when she was at the facility. VI. Staff interviews The DON was interviewed on 6/30/21 at 11:36 p.m. She reviewed and acknowledged the documentation on the resident's MAR dated 3/1/21, which revealed the resident did not receive her physician ordered [MEDICATION(S)] six times and was administered the [MEDICATION(S)] six times. -However this was inaccurate according to the Pharmacy delivery form, the medication was not in the facility to administer to the resident. -The DON said this medication was not kept in the facility's computerized medication dispensing machine and it had to come from the pharmacy. She said if medication was not available, a nurse should call the resident's physician and the pharmacy to see when the medication would be delivered to the facility. -The DON said she first learned of this concern on 6/29/21 after the survey started, when she was asked to provide additional documentation on this issue. The clinical resource representative (CRR) was interviewed on 6/30/21 at 12:00 noon. She reviewed and acknowledged the documentation on the resident's MAR dated 3/1/21, which revealed the resident did not receive her physician ordered [MEDICATION(S)] six times and was administered the [MEDICATION(S)] six times. She said this medication was not in the facility's computerized medication dispensing machine and was not sure when the medication was delivered to the facility. She did agree that multiple staff members had charted if the medication was not available and had also charted the medication that was administered to the resident. -The CRR said she first became aware of the concern on 6/29/21 after the survey started. She said if a medication was not available, the staff member should call the pharmacy and see if it had been delivered. If it had not been delivered, the staff member should call the resident's physician and see if there was an alternative medication that could be utilized or if it was appropriate for the facility to wait until the medication was delivered by the pharmacy. The medication technician (MT) #2 was interviewed on 6/30/21 at 12:26 p.m. She reviewed and acknowledged the documentation on the resident's MAR dated 3/1/21. She said she documented three times on the MAR the number 7 which meant 'other' (see nurses note pertaining to the administration of the medication). The nurse notes were initiated to reveal the medication was not available. She said if the medication was not available she would tell a nurse and it would be that nurse's responsibility to call the resident's physician and the pharmacy. She said she did not call either of them herself. The licensed practical nurse (LPN) #2 was interviewed on 6/30/21 at 1:39 p.m. She reviewed the resident's MAR dated 3/1/21 and said she did not administer the [MEDICATION(S)] one time, because it was not available. She said the number 7 meant other (see nurse note). She reviewed the corresponding nurse note and agreed it revealed the medication was not available. She said if there was a check mark with staff initials, then the medication had been administered. She said if medication was not available she would call the resident's physician and let them know. She would also call the pharmacy to see when the medication would be delivered. She said there was no documentation in her nurse's note that this was done. The DON was interviewed on 6/30/21 at 1:47 p.m. She said a check mark with staff initials meant the medication was administered. She said [MEDICATION(S)] was an anticoagulant medication and was ordered for this resident as a prophylactic measure. She said this medication was used to to prevent the potential occurrence for the development of an embolism (obstruction in an artery which was typically a clot of blood) or the development of a [CONDITION(S)] (blood clot in a blood vessel). The DON was interviewed on 7/1/21 at 10:20 a.m. She said the computerized pharmacy delivery form revealed the [MEDICATION(S)] was delivered to the facility on [DATE] at 11:50 a.m., and the form was signed by a nursing staff member. She said she had spoken with several of the staff members that had initialed the medication was administered and they all agreed if they documented it was administered, then they did administer the medication. -At 11:51 a.m. the DON said the hospital's discharge medication list was placed into the facility's computerized physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said all of the resident's medications were delivered to the facility on [DATE], except for the [MEDICATION(S)]. She said the [MEDICATION(S)] was delivered on 3/9/21. The DON said when the admission medication orders were faxed to the pharmacy, the facility did not receive anything from the pharmacy that the [MEDICATION(S)] was not available. She said there was no documentation the pharmacy was called by facility staff on the day the medications were delivered and that the [MEDICATION(S)] was not received by the facility. She said a nurse note dated 3/5/21 at 8:18 a.m., revealed the pharmacy was notified of the need for the [MEDICATION(S)]. -At 12:16 p.m., the DON said it was the responsibility of the nurse that received the medications from the pharmacy to ensure the accuracy of all the medications that were delivered. The nurse was also to notify the pharmacy if there were any discrepancies in the delivery. VII. Conclusion The facility failed to ensure Resident #87 received her [MEDICATION(S)] as the physician ordered. The resident arrived at the facility on 3/3/21. There was no documentation that the pharmacy was alerted by the facility that the [MEDICATION(S)] had not been delivered with all the other resident's admission medications. The resident's [DATE]/1/21 revealed the resident received the medication six times and had not received the medication six times. The pharmacy delivered the medication on 3/9/21 at 11:50 a.m.

Based on observation, record review and interviews the facility failed to maintain an infection program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as coronavirus (COVID-19) in one of two units. Specifically, the facility failed to ensure the use of proper personal protective equipment (PPE) in resident isolation rooms #502, #506, #509 and #520. I. Professional reference According to Center for Disease Control (CDC) guidance, Responding to Coronavirus (COVID-19) in Nursing Homes Considerations for the Public Health Response to COVID-19 in Nursing Homes, updated 4/30/2020, retrieved online 7/6/21 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html Even as nursing homes resume normal practices and begin relaxing restrictions, nursing homes must sustain core infection control (IPC) practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP (heathcare personnel) in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. Residents with confirmed [CONDITION(S)]-CoV-2 infection who have not met criteria for discontinuation of Transmission-Based Precautions should be placed in the designated COVID-19 care unit. In general, all other new admissions and readmissions should be placed in a 14-day quarantine, even if they have a negative test upon admission. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. II. Facility policy The Infection Control policy, revised on March 2021, provided by the director of nurses (DON) on 6/28/21 at 11:00 a.m. read in pertinent part; The policy of the facility that the spread of infections will be prevented by placing a resident in a private isolation room. The procedures or precautions for COVID-19 positive residents and for COVID-19 unknown residents included wearing an N95 mask, eye protection, gowns and gloves. III. Observations and interviews of PPE not worn correctly in isolation rooms On 6/28/21 at 11:35 a.m., a sign on the door to room [ROOM NUMBER] revealed was on droplet precautions due to a recent admission to the facility on [DATE]. He was seated in a chair by the window and was not wearing a mask. His wife, who was visiting the resident, sat in a chair beside the resident and was not wearing any personal protection equipment (PPE). She said it was her understanding, she did not have to wear all of the PPE because she had received both vaccinations for COVID-19. On 6/28/21 at 11:52 a.m., registered nurse (RN) #2 went into room [ROOM NUMBER]. She only wore a surgical mask and was not wearing a gown, gloves, N95 mask or eye protection as indicated, since the resident was on droplet precautions. She stood approximately six feet from the resident and his wife during their verbal interaction. She did not remove the surgical mask (she should have worn a N95 mask while in the room) when she left the room. She should have put on a new mask prior to leaving the resident's room. On 6/28/21 at approximately 1:00 p.m., medication technician (MT) #2 said the resident's wife and RN #2 should have worn a gown, gloves, N95 mask and eye protection prior to entrance to room [ROOM NUMBER]. She said the resident in room [ROOM NUMBER] was on droplet precautions. On 6/28/21 at 2:25 p.m., the director of nursing (DON) said RN #2 as well as the resident's wife should have been wearing full PPE (gown, gloves, N95 mask and eye protection) prior to entering into room [ROOM NUMBER]. On 6/29/21 at 12:35 p.m., RN #2 said she should have donned full PPE (gown, gloves, N95 mask and eye protection) before she entered room [ROOM NUMBER]. She acknowledged she was not wearing the appropriate PPE for the observation on 6/28/21 at 11:52 a.m. On 7/1/21 at 7:42 a.m., the DON provided the Visitation Guidelines that included the requirements for PPE (gown, mask, gloves and eye protection ) prior to entrance into room [ROOM NUMBER]. -This document was signed by the resident's wife on 6/23/21 at 2:00 p.m. IV. Additional observations and interviews of PPE not worn correctly The dietary aide (DA) was observed on 6/28/21 at 11:53 a.m. to deliver lunch trays to residents' rooms. She delivery a tray to an isolation room [ROOM NUMBER]. She walked into the room with just a surgical mask on. Without gloved hands she moved things around on the bedside table to make room for the food tray. She left the room, performed hand hygiene and delivered a lunch tray to isolation room [ROOM NUMBER]. She wore the same surgical mask and no other PPE. She left the room once and came back with a soda for the resident. She left the room performed hand hygiene and entered resident isolation room [ROOM NUMBER]. She put the tray on the bedside table and took the dirty breakfast tray out of the room with her bare hands. She put the dirty tray in the utility room across the hallway and entered room [ROOM NUMBER] again with beverages for the resident. The sign on the doors read droplet precautions and there was an isolation cart outside of all the isolation rooms. The dietary aide (DA) was interviewed on 6/28/21 at 12:10 p.m. She said she had worked at the facility for about a month. She said she was trained to wear personal protective equipment in isolation rooms when they had COVID-19. She said she watched a video but did not have anyone show her in person how to put the PPE on. She said she was not sure if she needed to wear the PPE in the isolation room to deliver food trays. She said she knew she had to offer the residents hand hygiene spray when she delivered the residents tray to them. Immediately after the interview with the DA delivered another room tray to isolation room [ROOM NUMBER] without wearing proper PPE. The wound nurse (WN) was interviewed on 6/28/21 at 12:25 p.m. She said full PPE gear to include N95 mask, gown, gloves and eye protection was worn in an isolation room. She said she was told to follow the state guidelines to prevent the spread of COVID-19. The director of nurses (DON) was interviewed on 6/28/21 at 2:09 p.m. She said staff had to wear full PPE gear to include an N95 mask, a face shield, gown and gloves. She said any new residents were placed in an isolation room until the status of their COVID-19 vaccine was verified. She said residents were presumed positive until then. She said the sign on the door and the isolation cart outside the residents room showed the staff the resident was in isolation and she expected the staff to wear the appropriate gear in the isolation room. She said monthly training occurred with updates on infection control and PPE. She said pathogens can spread when PPE was not worn correctly in isolation rooms. V. Facility follow-up Follow-up training was provided by the director of nurses (DON) on 6/28/21 at 3:17 p.m. The donning and doffing of personal protective equipment (PPE) on 6/28/21 revealed the steps on how to don and doff PPE. There were signatures of 31 staff members and the DA was on the list of educated staff. VI. Facility COVID-19 status The director of nurses (DON) was interviewed on 6/27/21 at 8:40 a.m. She said they had zero COVID-19 positive residents and six COVID-19 presumptive positive residents.

Based on record review and interviews, the facility failed to ensure an adequate system was in place to include a process for timely ordering and delivery of medications for one (#87) of five out of 25 sample residents. Specifically, the facility failed to ensure Resident #87's anticoagulant medication was ordered and delivered to the facility in a timely manner. Findings include: I. Facility policies and procedures The Pharmacy Services policy, updated 1/2019, was provided by the director of nursing (DON) on 7/1/21 at 11:56 a.m. The policy revealed by written agreement, arrangements shall be made to assure that pharmaceutical services were available to provide residents with prescribed drugs and biologicals both routine and emergency. The Requirement of Pharmacy policy, updated 1/2019, was provided by the DON on 7/1/21 at 11:56 a.m. The policy revealed the pharmacy would provide 24-hour prescription service on a prompt and timely basis of drugs and biologicals. The facility would be notified of any medication that was not available until the next day. The Pharmacy General Information policy, updated 1/2019, was provided by the DON on 7/1/21 at 11:56 a.m. The policy revealed on-call service was available at all times 24 hours daily, 365 days a year. Medication orders must be placed two hours before scheduled delivery times of Monday through Friday; priority delivery at 10:00 a.m., first delivery at 2:00 p.m., second delivery at 5:00 p.m. and third delivery at 8:00 p.m. New admission medications would be delivered throughout the day. New admission and new orders should follow the fax cutoff and departure times. If it was after hours, remember to call if the medications were needed prior to the next scheduled delivery. II. Resident status Resident #87, age 59, was admitted on [DATE] and discharged on [DATE]. According to the March 2021 computerized physician orders (CPO), diagnoses included unstable burst fracture of the first lumbar vertebra, multiple fractures of ribs on the left side, unspecified fall, and stage III [CONDITION(S)]. The 3/8/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required extensive staff assistance for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident received an anticoagulant medication five times during the seven day assessment period. III. Record review The care plan for the use of an anticoagulant therapy ([MEDICATION(S)]) related to post surgery was initiated on 3/5/21. The goal for the resident was to be free from discomfort or adverse reactions related to the use of an anticoagulant medication. One of the interventions was to monitor and report any signs/symptoms of thromboembolism: acute onset of shortness of breath, pleuritic chest pain, cough, coughing up blood, [CONDITION(S)] and anxiety. Physician's order dated 3/3/21 at 3:00 p.m., revealed to administer [MEDICATION(S)] (anticoagulant) tablet 15 milligrams (mg) orally twice daily as a prophylaxis for 21 days. The computerized pharmacy delivery form provided by the DON on 6/30/21 at approximately 1:00 p.m., revealed the anticoagulant [MEDICATION(S)] 15 mg was delivered to the facility on [DATE] at 11:50 a.m. This form was signed by a nursing staff member. -This indicated the resident missed six doses of [MEDICATION(S)]. Cross-reference F760 IV. Staff interviews The DON was interviewed on 6/30/21 at 11:36 p.m. She said this medication was not kept in the facility's computerized medication dispensing machine and it had to come from the pharmacy. She said if a medication was not available, a nurse should call the resident's physician and the pharmacy to see when the medication would be delivered to the facility. The clinical resource representative (CRR) was interviewed on 6/30/21 at 12:00 noon. She said this medication was not in the facility's computerized medication dispensing machine and was not sure when the medication was delivered to the facility. -The CRR said if a medication was not available, the staff member should call the pharmacy and see if it had been delivered. If it had not been delivered, the staff member should call the resident's physician and see if there was an alternative medication that could be utilized or if it was appropriate for the facility to wait until the medication was delivered by the pharmacy. The medication technician (MT) #2 was interviewed on 6/30/21 at 12:26 p.m. She said if the medication was not available she would tell a nurse and it would be that nurse's responsibility to call the resident's physician and the pharmacy. She said she did not call either of them herself. The licensed practical nurse (LPN) #2 was interviewed on 6/30/21 at 1:39 p.m. She said if a medication was not available she would call the resident's physician and let them know. She would also call the pharmacy to see when the medication would be delivered. She said there was no documentation in her nurse's note that this was done. The DON was interviewed on 7/1/21 at 10:20 a.m. She said the computerized pharmacy delivery form revealed the [MEDICATION(S)] was delivered to the facility on [DATE] at 11:50 a.m., and the form was signed by a nursing staff member. -At 11:51 a.m. the DON said the hospital's discharge medication list was placed into the facility's computerized physician's orders on 3/3/21. This was the resident's date of admission. She said all of the resident's medications were delivered to the facility on [DATE], except for the [MEDICATION(S)]. She said the [MEDICATION(S)] was delivered on 3/9/21. The DON said when the admission medication orders were faxed to the pharmacy, the facility did not receive anything from the pharmacy that the [MEDICATION(S)] was not available. She said there was no documentation the pharmacy was called by facility staff on the day the medications were delivered and that the [MEDICATION(S)] was not received by the facility. She said a nurse note dated 3/5/21 at 8:18 a.m., revealed the pharmacy was notified of the need for the [MEDICATION(S)]. -At 12:16 p.m., the DON said it was the responsibility of the nurse that received the medications from the pharmacy to ensure the accuracy of all the medications that were delivered. The nurse was also to notify the pharmacy if there were any discrepancies in the delivery. V. Conclusion The facility failed to ensure Resident #87 received her [MEDICATION(S)] as the physician ordered. The resident arrived at the facility on 3/3/21. There was no documentation that the pharmacy was alerted by the facility that the [MEDICATION(S)] had not been delivered with all the other resident's admission medications. The pharmacy delivered the medication on 3/9/21 at 11:50 a.m.

Based on record review, observation and interviews, the facility failed to ensure two (#1 and #2) residents received care to prevent pressure ulcers and did not develop avoidable pressure ulcers; and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure both Resident #1 and Resident #2 did not sustain avoidable facility acquired pressure ulcers. The facility failed to ensure the accuracy of the pressure ulcer risk assessment, increase monitoring of Resident #1's skin, implement timely interventions to avoid skin breakdown. The interventions that were implemented, the facility failed to ensure were provided to the resident. Resident #1 sustained two pressure ulcers, one which healed and with the second pressure ulcer, he was sent to the hospital to see if he was a surgical candidate for the decline in his wound. The facility failed to ensure Resident #2 who was admitted on [DATE], without pressure ulcers, did not develop avoidable pressure ulcers shortly after his admission. The facility's additional failures to accurately document a pressure ulcer risk assessment, timely assess, contributed to the delay in appropriate care and treat to Resident #2. Resident #2 sustained a wound to his coccyx which required surgical debridement of the wound, which had exposed muscle. Furthermore, the resident sustained [REDACTED]. See observation and interviews. Cross-reference F641 for accuracy of assessments. Findings include: I. Facility policy and procedure The Pressure Ulcer Skin Monitoring and Management policy, October 2020, was provided electronically by the clinical resource (CR) on 1/20/21 at 4:30 p.m. It read in pertinent part: It is the policy of this facility that: A resident that enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new avoidable sores from developing. The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services to: -Promote the prevention of pressure ulcer development; -Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and -Prevent the development of additional avoidable pressure ulcers. The nurse responsible for assessing and evaluating the resident's condition on admission and readmission is expected to take the following actions: -Complete comprehensive admission assessment/evaluation and Braden scale to identify risk and to identify any alterations in skin integrity noted at the time. The Braden is completed upon admission, readmission, quarterly, annually and with significant change. -Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure ulcers. -All risk factors identified on assessment should be documented in the resident's chart and when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. -A licensed nurse must assess a resident's skin on admission. All areas of breakdown, excoriation, or other unusual findings must be documented. -A licensed nurse must assess a wound upon admission and weekly. -A licensed nurse must assess a resident's skin weekly. -Assessment of wounds identified after admission must have an interdisciplinary (IDT) or skin wound progress note. New wounds will be communicated to the IDT team through risk management. Evaluation/assessment should include but not be limited to: -Measurements, staging, description of the nature of the wound, description of the location of the wound, characteristics of the wound, description of the healing progress and/or any barrier to healing, and identify any possible complications consistent with the possibility of infection. -Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area per the physician order. -All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. -In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall: Refer the resident to the wound care physician and continue preventative measures as appropriate, including: Pressure reduction, incontinence care, mobility, nutrition management, and hydration management. -Re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations if any wound is not healing or not showing improvement. The Skin Assessment policy, May 2018, was provided electronically by the CR on 1/20/21 at 4:30 p.m. It read, in pertinent part: It is the policy of this facility to assess all residents upon admission, when a comprehensive assessment is required and quarterly thereafter to identify risk of skin breakdown. The purpose is to identify residents at risk for skin breakdown and institute appropriate preventative measures. -All residents will be assessed for skin risk using a pressure ulcer risk assessment form (Braden) within 24 hours of the time of admission by the licensed nurse. -Residents will be re-assessed (sic) for skin risk when a comprehensive assessment is required, quarterly and with significant change. -Nursing and dietary will monitor dietary intake and weight patterns on an ongoing basis to identify residents at risk for malnutrition and skin breakdown. -Weekly skin evaluations will be completed by a licensed nurse weekly and as needed. II. Resident #1 A. Resident status Resident #1, age 76, was admitted on [DATE], readmitted on [DATE], and discharged to the hospital on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. The 12/14/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a staff assessment for mental status revealing the resident exhibited short and long term memory problems and moderately impaired decision making skills. He required extensive or total assistance of one to two staff members with mobility and activities of daily living (ADLs). He had an indwelling foley catheter and was always incontinent of bowel. He had one stage two pressure injury and one unstageable pressure injury presenting as a deep tissue injury. He had pressure reducing devices for his bed and wheelchair, was on a turning and repositioning program and had nutrition and hydration interventions, as well as wound care and dressing changes. B. Record review Resident #1's admission assessment was completed on 11/15/2020 and revealed the resident did not have any skin problems on admission to the facility and read the resident's heels, elbows and coccyx were clean, dry and intact. The admission, Braden scale for predicting pressure sore risk was completed on 11/15/2020 and revealed the resident was low risk for developing pressure sores. The assessment revealed the resident had slightly limited sensory perception, his skin was rarely moist, he was bedfast, he had slightly limited mobility, he had adequate nutrition, and potential for friction or shear. Resident #1 was sent to the hospital on [DATE] due to abnormal lab values. Resident #1 returned to the facility on [DATE], the readmission skin assessment revealed the resident returned to the facility with redness to his groin and coccyx area. The Braden scale completed on 11/24/2020 scored the resident as low risk for developing pressure sores. The assessment read the resident had no impairment in sensory perception, his skin was occasionally moist, he was chairfast, his mobility was slightly limited, his food intakes were probably inadequate for nutrition, and he had a potential problem for friction and shear. A skin care plan was initiated on 11/25/2020, it read in pertinent part: The resident has potential for pressure ulcer development, was admitted with non blanchable redness to his buttocks and bilateral groin. The goal read: Will have intact skin, free of redness or discoloration by/through the review date. Pertinent interventions included: Administer treatments as ordered and monitor for effectiveness; Encourage fluid intake and assist to keep skin hydrated; Monitor nutritional status. Serve diet as ordered, monitor intake and record; Monitor, document and report to MD as needed changes in skin status: appearance, color, wound healing, signs or symptoms of infection, wound size and stage; Needs monitoring/reminding/assistance to turn and reposition; Notify the nurse immediately of any new areas of skin breakdown; Out of bed unless contraindicated; Requires pressure relieving or reducing device on bed and chair; Weekly head to toe skin at risk assessment. On 11/25/2020 through 12/3/2020 the resident's daily skilled assessments revealed the resident was alert to himself, was a maximum assist of two to three staff members for bed mobility, he had redness to his scrotum and coccyx with barrier cream applied with each brief change. There was no documentation or indication of interventions such as pressure reducing devices, turning and repositioning programs or nutrition hydration interventions on the daily skilled assessment. On 11/25/2020 a nutritional progress note revealed the resident was at risk for weight loss and nutritional issues due to decreased appetite and COVID-19 recovery. He was also documented to have issues meeting hydration needs. Orders for Ensure once a day were added. On 11/27/2020 a nursing note revealed the resident was very sleepy. Orders from the physician were to push fluids, protein, and (brand name of electrolyte drink). An MDS assessment was completed on 11/30/2020 and revealed the resident required extensive assistance of two staff members with mobility, transfers, and ADLs. He was frequently incontinent of bowel and bladder. He had swallowing difficulties while eating and drinking and was on a mechanically altered diet. He was at risk of developing pressure injuries, though had no pressure injuries at the time of the assessment. -He was documented to have had a pressure reducing devices for his bed and chair, though was not on a turning and repositioning program, and was not receiving nutrition or hydration interventions. -These interventions would not be appropriate for someone who is extensive assistance with transfers to not have at least an alternating mattress in place to help prevent the development of pressure ulcers. The alternating air mattress was not implemented until 12/9/2020 after he developed an open pressure ulcer. A weekly skin assessment was completed on 12/1/2020 and revealed the resident had no problems with chewing at the time. He had redness to his scrotum and barrier cream was applied. On 12/2/2020 a weekly skilled review IDT note revealed the resident was started on intravenous fluids (IV) for hydration and one to one feeding assistance due to decreased intake and functional decline. On 12/4/2020 through 12/8/2020 the daily skilled assessments indicated the resident continued to be alert to himself, he remained maximum assist of two or three staff for bed mobility and a full body mechanical lift for transfers. He continued to have redness to his scrotum and coccyx and barrier cream was used after brief changes. The assessment on 12/4/2020 indicated a pressure reduction mattress and chair cushion were used, though no turning and repositioning program or nutrition hydration interventions were indicated. On 12/8/2020 a weekly skin assessment was completed and revealed the resident had an open area to his buttock, his left elbow was red, blanchable and boggy with sureprep applied and a sponge cushion for protection. His scrotum was red and barrier cream was applied. No measurements or description of the open area were included. -There was no documentation of additional actions, orders or interventions related to the open area identified. On 12/9/2020 the daily skilled assessment revealed the resident had a foley catheter for incontinence, an open area to his coccyx and had been put on an alternating air mattress for pressure reduction. No measurements of the open area to the resident's coccyx were included. There were no other interventions or actions indicated on the assessment related to the open area that was identified. Resident #1 was seen by the wound physician on 12/10/2020 for wounds identified to his sacrum and left buttock. The sacral wound was described as an unstageable pressure injury which measured 5.5 cm length x 1.5 cm width x 0.5 cm depth. Muscle was exposed, the resident reported no pain. The wound bed was 50% eschar and 50% slough. The periwound texture, moisture and color were normal. The wound was debrided and orders were written to clean the wound with normal saline, apply dakins soaked gauze packing and cover the wound with a foam dressing daily. The buttock wound was a pressure ulcer which measured 2.5 cm length x 1.5 cm width x 0.1 cm depth. No pain was reported and the wound bed was 100% granulation. Orders were written to clean the wound with normal saline, apply [MEDICATION NAME] and cover with a foam dressing daily. On 12/11/2020 the daily skilled assessment revealed the resident had a stage 2 pressure ulcer on his sacrum and an unstageable pressure ulcer on his sacrum. On 12/12/2020 the daily skilled assessment revealed the resident was on a one to one feeding program due to loss of liquids and pocketing food while eating. The urine in the foley catheter bag was amber color with sediment. The resident had a stage two pressure ulcer to his sacrum and an unstageable ulcer to his rectum and was on a pressure reducing device. On 12/13/2020 the daily skilled assessment revealed the resident had dark cloudy urine in the foley bag and an unstageable sore to his rectum and a stage 2 to his sacrum. No interventions or devices were indicated. The resident was seen by the wound physician again on 12/14/2020. The buttock wound had resolved. -This indicated Resident #1 had the ability to heal and the wound was avoidable. -The sacral pressure ulcer measurements were 5 cm length x 2 cm width x 2.8 cm depth. Muscle was exposed and the wound bed was 100% slough. The wound was deteriorating. The wound was debrided. The treatment orders were increased to twice a day and as needed. The wound physician recommended a CT scan due to concern for colocutaneous fistula. On 12/14/2020 a physician assistant progress note revealed the resident was seen to follow up on the resident's wound at the request of the wound physician. The note revealed the unstageable sacral wound was draining malodorous brown liquid and the staff were repositioning the resident every two hours or sooner. The physician would order a CT scan to occur before the end of the week as long as the resident did not develop any indications of septic infection. On 12/14/2020 the daily skilled assessment revealed the resident had an open sore to his coccyx and was receiving a treatment to the wound and a dressing change was completed. No other interventions were indicated. On 12/14/2020 a nutrition note revealed the resident continued with inconsistent intakes and needed one to one assistance and encouragement. The note acknowledged the open area to the resident's buttocks and to order ensure once a day and prostat once a day to help meet needs and promote skin healing. On 12/15/2020 a physician progress notes [REDACTED]. The note revealed the resident had a sacral wound with deep tracking noted, very malodorous brown drainage from the wound and when pressure is applied more purulence was expressed. The physician noted after seeing the wound today I do not feel comfortable waiting to have a CT, I feel patient may need surgical intervention and will send to the hospital for evaluation. -Unfortunately the resident was not a surgical candidate and would have to continue to endure wound treatments (see hospital records). C. Additional failures Review of Resident #1 medication and treatment administration records for November and December 2020 revealed: An order to apply barrier cream to groin, coccyx, sacrum, and bilateral buttocks each shift was written on 11/24/2020. The record revealed no documentation of barrier cream being applied on night shift on 12/3/2020, or on day shift on 12/12/2020 and 12/13/2020. an order for [REDACTED]. An order to cleanse the left buttock with normal saline, apply [MEDICATION NAME] and cover with foam dressing once daily was written on 12/10/2020 and to be held on 12/14/2020. The order was documented to have been completed on 12/11/2020. There was no documentation of the dressing being completed on 12/12/2020 or 12/13/2020. An order to cleanse the open area to the coccyx with normal saline, pat dry and apply [MEDICATION NAME] and dry dressing was written on 12/9/2020 and discontinued on 12/15/2020. There was no documentation of the treatment order being completed on 12/12/2020 or 12/13/2020. An order to cleanse the sacral wound with normal saline, soak gauze in dakin's solution and cover with ABD pad and foam dressing was written on 12/10/2020 and discontinued on 12/14/2020. There was no documentation of the treatment order being completed on 12/12/2020 or 12/13/2020. The treatment was documented to be completed on 12/11/2020 and 12/14/2020. An order to check and change and turn and reposition the resident every two hours was written on 12/15/2020. The resident was discharged to the hospital the same day. The residents ADL documentation was reviewed for November and December 2020 and revealed inconsistent documentation of services provided to the resident in relation to his needs. Specifically, on multiple days, the resident was only documented to have been turned once. Multiple days showed the resident was only toileted twice and personal hygiene was not provided. Review of the documented services provided to the resident indicated the resident was not receiving all of the care ordered or expected for a resident at risk for skin breakdown or pressure injuries. D. Hospital records The resident's hospital records were obtained electronically on 1/19/2020 at 2:00 p.m. The notes revealed the resident was admitted to the hospital [MEDICAL CONDITION] due to urinary tract infection and infected sacral wound. A CT scan performed at the hospital confirmed an anal fistula which was the source of the infection and contributory to the rapid decline of the wound. Resident #1 was not a candidate for surgical intervention for the wound so was discharged from the hospital to a sub acute rehabilitation facility on 12/23/2020. E. Interviews The wound care physician was interviewed on 1/20/21 at 10:53 a.m. He stated he visited the facility weekly and as needed upon request and he rounded with the facility wound nurse. He stated he saw each patient on his list individually and examined wounds completing measurements, assessments, determining etiology, debridements if needed and treatments and writing treatment orders when needed. He stated he remembered Resident #1 and stated he believed the resident had a deep tissue injury that opened up and deteriorated rapidly due to previous COVID-19 infection and possible fistula. The resident's physician was interviewed on 1/20/21 at 12:09 p.m. She stated she comes to the facility weekly conduct rounds on patients. She stated she is informed of skin issues and pressure injuries through the electronic system. She stated she orders for residents with skin issues to be followed by wound care as they are the wound and treatment experts. She stated Resident #1 was very debilitated due to recent COVID-19 infection and [MEDICAL CONDITION]. She stated he had mental status changes and was assessed by either herself or physician assistants every few days. She stated they performed multiple sets of labs on the resident to try to determine the source of the mental status changes and decline. She stated she and her team were informed of the resident's open area, she ordered a temporary treatment until the wound doctor could come in and assess the area. She stated within a couple days she was informed the wound was worse and was draining brown liquid with an odor. She stated she came to the facility the next day and felt he needed to be sent to the hospital for evaluation. Certified nurse aide (CNA) #1 was interviewed on 1/20/21 at 12:31 p.m. She stated she turned and repositioned residents every two hours at least and used her own opinion of who needed help and who did not. She stated she also followed what therapy and the nurses told her to do. She stated if she discovered a skin issue of any kind on a resident she would tell the nurse right away. CNA #2 was interviewed on 1/20/21 at 12:40 p.m. She stated all residents needed help turning and repositioning every two hours. She stated she reported all skin issues to the nurse. She stated she documented all services provided to the residents in the computer every shift and there was no reason she could think of that she would not document all of her tasks. Licensed practical nurse (LPN) #2 was interviewed on 1/20/21 at 2:07 p.m. She stated residents should be turned every two hours. She stated she looked at resident's skin every shift because it was part of the daily skilled assessment. She stated braden scales and full head to toe assessments were completed upon admission and then head to toe skin checks were done every week after that. She stated if a new skin issue was discovered, a risk management report needed to be filled out and then reported to the director of nursing (DON) assistant director of nursing (ADON) and physician and family needed to be informed. The DON was interviewed on 1/20/21 at 2:15 p.m. She stated the CNAs were responsible for documenting all tasks like transfers, turning and repositioning, toileting and hygiene. She stated all residents who need these services should have documentation at least three times a day. She stated there should not be any areas not filled in the documentation for nurses or CNAs. She stated Resident #1 had multiple comorbidities and was resistive to care, reluctant to turn, and had poor intakes. She stated the wound care program at the facility had had some problems since November or December 2020 due to staff turn over and having to hire a new ADON who is responsible for wound care in the facility. The CR was interviewed on 1/20/21 at 2:25 p.m. She stated a resident who needed extensive assistance with bed mobility and transfers, who was in their bed or chair all of the time, and who had poor nutritional intake should at least be moderate risk on the braden scale, she could not explain why Resident #1 was low risk on both of the bradens completed for him. She stated the wound care program at the facility had identified problems and that she and the DON had started an action plan to include education of staff, better monitoring and daily/weekly meetings of relevant staff to ensure all residents at risk and all residents with existing pressure injuries receive the care and monitoring that was necessary and needed to prevent and heal pressure injuries and wounds. III. Failed to monitor and treat two unstageable pressure injuries timely for Resident #2 A. Resident status Resident #2, age 81, was admitted on [DATE]. According to the computerized physician orders [REDACTED]. The 12/17/2020 minimum data set (MDS) assessment, documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. Resident #2 required extensive one person assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. He was occasionally incontinent of the bladder. He had one stage two pressure injury and was at risk for pressure injuries. B. Record review The residents admitting [DIAGNOSES REDACTED]. The resident had an admitting [DIAGNOSES REDACTED]. However, unlike his other diagnoses, the [DIAGNOSES REDACTED]. The history and physical dated 12/11/2020, did not list the pressure injury. There was no assessment of a pressure injury documented in the electronic medical record (EMR) until 12/20/2020. The nurses progress notes were reviewed. The nurses notes documented the following: -On 12/12/2020 at 2:10 p.m. Skin was documented as good. -On 12/14/2020 at 11:32 a.m. his skin was documented as CDWI (clean, warm, dry and intact). -On 12/15/2020 at 10:50 p.m. his skin was documented as WD (warm and dry). -On 12/16/2020 at 10:44 p.m. and 12/18/2020 at 11:55 p.m. his skin documentation revealed, heels, coccyx and elbows CDI (clean, dry and intact). There was no documentation of a pressure injury since admission 12/12/2020, despite the MDS assessment documenting a pressure injury stage two as of 12/17/2020, and the admission [DIAGNOSES REDACTED]. On 12/20/2020 at 2:45 p.m. there was a change of condition note that documented the resident had a new wound to his left buttock which developed on 12/18/2020. The note further documented the physician was notified 12/19/2020. The wound measurements were 4 cm (centimeters) x 2 cm x 0.1 cm. The wound was described as 100% epithelization (new skin covering wound). There was no further assessment documented of this wound by the facility until 12/31/2020, 11 days later. The December 2020 treatment administration record (TAR) was reviewed. There was no treatment for [REDACTED]. On 12/29/2020 at 8:28 a.m., the weekly skin assessment documented the resident had two open areas. -There was no documentation on the weekly skin assessment of what either open area measured, the appearance, or status. On 12/31/2020, the wound care physician documented, Coccyx is an unstageable pressure injury, obscured full-thickness skin and tissue loss. Initial wound encounter measurements are 0.6cm length x 0.5cm width x 0.1cm depth, with an area of 0.3 sq cm and a volume of 0.03 cubic cm. Muscle is exposed. Wound bed has 90% slough (dead skin tissue). The wound was surgically debrided (removal of dead or necrotic tissue), The new measurements were 0.6cm length x 0.5cm width x 0.3cm depth; with an area of 0.3 sq cm and a volume of 0.09 cubic cm. The physician had reclassified the wound from the left buttock, as the facility had documented, to coccyx. -The wound was not assessed for 10 days, 12/21/2020 through 12/31/2020, and had deteriorated. On 1/7/2020, the wound notes documented the coccyx wound was 0.3 X 0.3 X 0.1 cm, 100% slough. On 1/14/2020, the wound note documented the coccyx wound was 0.3 x 0.3 X 0 cm, 100% [MEDICATION NAME]. There was no further documentation in the EMR of a second wound, being monitored, treated or healed. The Braden skin breakdown risk assessment tool dated 12/12/2020 was reviewed. The Braden assessment was completed on 12/12/2020 and documented the resident was at low risk for skin breakdown, despite his need for extensive assistance with bed mobility and occasional incontinence. -There were no further skin risk assessments completed after the wound development. The care plan initiated 12/21/2020 documented, Resident #2 has actual impairment to skin integrity related to 4 cm x 3/4 cm open area on left buttock, therapy evaluation and treatment per physician orders, follow facility protocols for treatment of [REDACTED]. In addition, there was a care plan initiated 12/15/2020, and revised 12/21/2020 that documented, Resident #2 has actual impairment to skin integrity, with interventions, keep skin clean and dry, monitor for side effects of the antibiotics and over-the-counter pain medications: [REDACTED]. The physical therapy notes dated 12/13/2020 and 12/14/2020 documented the resident needed moderate assistance with bed mobility. The notes further documented Resident #2 needed max encouragement to get out of bed. The registered dietician (RD) notes were reviewed. There were no notes related to the wounds. C. Interviews Certified nurse aide (CNA) #1 was interviewed on 1/19/21 at 4:11 p.m. She said she did not know if Resident #2 had any wounds. She said the resident was stand by for assistance with transfers and can move himself in the bed. Licensed practical nurse (LPN) #1 was interviewed on 1/19/21 at 4:15 p.m. She said Resident #2 has two pressure ulcers on his buttocks. She said she saw a new pressure ulcer last Sunday, 1/17/21. LPN #1 said he has had the second one before, it was closed though and has now reopened. LPN #1 said the process was when a new wound was observed, the nurse should notify the physician, obtain orders, notify the family, and document a note describing the wound. The nurse notes were reviewed for the previous Sunday 1/17/21. There was no documentation regarding a new or reopened wound on 1/17/21 or 1/18/21. Additionally, LPN #1 said she had started working on the day shift around 12/13/2020, and Resident #1 already had a wound on his left buttock at that time. There was no assessment documented of any wound in the nurses notes until 12/20/2020. The medical records coordinator (MRC) was interviewed on 1/20/21 at 10:00 a.m. She said she added the [DIAGNOSES REDACTED]. She said the MDS nurse told her to add the diagnosis. She said it was not in his admitting notes or his history and physical. The MRC said she should not have done this, as the wound developed after admission. The assistant director of nursing (ADON) was interviewed on 1/20/21 at 10:21 a.m. She said she was also the wound nurse and assessed wounds every seven days or sooner. The ADON said when the nurses find a new wound they just tell me. She said if a nurse finds a wound she should notify the physician right away and get a treatment and then she will look at it the next day, or on Monday if it is a weekend. She said the nurse should document a description of what the wound looked like and what inter(TRUNCATED)

Based on observations, interviews, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, metal and psychosocial well- being for two ( #99, #305) out of 32 sample residents. This resulted in the prolonged and unrelieved pain for one (#99) out of the three residents. Specifically, the facility failed to: -Promptly and continuously implement a system of pain monitoring for resident #99 who was identified as being high risk for pain, resulting in the resident experiencing unrelieved severe pain; -Access the emergency kit to provide prescribed pain medications for resident #99 when ordered pain relief medications was unavailable, resulting in the resident experiencing unrelieved, severe pain; and -Monitor resident #305's bruising in order to identify new bruising. The findings included: Facility Policy The 8/2014 pain management program policy, furnished by the facility on 11/25/15, stated: Policy: It is the policy of this facility to provide a pain management program Procedures: 1. Pain is subjective and is what the resident says it is existing where and when the resident says it does 2. Acceptable/tolerable pain control is defined by the resident, this does not necessarily mean the resident is pain free 3. The pain scales can be used for any resident at any time and is determined by the resident's ability at the time of concern 4. Any resident receiving a pain medication will have the pain evaluated before and after PRN (as needed) administration 5. Pain evaluation is completed on admission, at least quarterly and as needed I. Resident #99 A. Resident Status Resident #99, age [AGE] years, was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The 11/4/15 admission minimum data set (MDS) revealed: -The resident was cognitively intact as evidenced by a brief interview for mental status (BIMS) of 15 out of 15. -The resident did not experience an acute change in mental status or signs and symptoms of [MEDICAL CONDITION]. -The resident did not exhibit behaviors the affected the self or others and did not exhibit rejection of cares. -The resident experienced frequent, severe pain during the five days that preceded the completion of the pain questionnaire. According to the resident, her pain limited her daily activities and affected nightly sleep. -The resident experienced a fall with facture prior to admission. -The resident required extensive assistance with bed mobility, transfers, and toilet use. -The resident required limited assistance with personal hygiene, dressing, locomotion on and off the unit and walking in room. The 10/29/15 pain risk evaluation revealed the resident had a score of 13 which assessment form indicated was high risk for pain. The first of three pain care plans, initiated on 10/29/15 and revised on 11/11/15, stated the resident was on medication therapy related to a pelvic fracture. The goal was for the resident to be free from adverse side effects of the pain medication. The approaches included: -Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. -Follow MD (physician) orders for weight bearing status. See MD orders and/or (physical therapy) PT treatment plan. -Monitor/document pain on a scale of 0 to 10 before and after implementing measures to reduce pain. -Therapy evaluation and treatment per orders. The second pain care plan, initiated on 10/29/15 and revised on 11/11/15, stated that the resident was on pain medication related to a pelvic fracture. The goal was that the resident would be free of any discomfort or adverse side effects from pain medication through the review date. Approaches included: -Administer medication as ordered. -Monitor for increased risk for falls. -Review pain medication efficacy. Assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed, but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. The third pain care plan, initiated on 10/29/15 and revised on 11/11/15, stated the resident had acute/chronic pain related to a pelvic fracture. The goal was for the resident to verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The approaches included: -Able to call for assistance when in pain. -Administer [MEDICATION NAME] medication as per orders. Give 1/2 (half) hour before treatments or care. -Anticipate need for pain relief and respond immediately to any complaint of pain. -Follow pain scale to medicate as ordered -Monitor/record pain characteristics: Quality (e.g. sharp, burning); Severity (1 to 10 scale); Anatomical location; Onset; Duration (e.g., continuous, intermittent); Aggravating factors; Relieving factors. -Occupational, Physical Therapy evaluation and treatment per physician orders [REDACTED]. B. Resident/Family Interviews An interview conducted on 11/19/15 at 3:37 p.m., with the resident revealed: The resident had experienced discomfort, such as pain, heaviness, burning or hurting with no relief during her stay at the facility. The resident stated that when she arrived at the facility she did not have scheduled pain medication. According to the resident, she had to utilize her call bell to request pain medication; however, her call bell was not working for the first two days. The resident stated she had to yell out for assistance, but that this was not effective because staff did not arrive to help her. The resident reported that certified nurse aide (CNA) #6 identified and addressed her non-functioning call light. The call light had needed to have the batteries replaced. The resident stated that staff did not routinely come in to inquire about her pain level in the first several days of her stay. According to the resident staff would ask about her pain levels when she requested pain medication. The resident stated her pain management was a problem again last night (overnight from 11/18 to 11/19). According to the resident, she ran out of [MEDICATION NAME] (pain medication) with the 8:00 p.m., dose. The resident stated her pain was a 15 out of 10 when staff provided the [MEDICATION NAME] to her at 5:00 a.m. According to the resident, she was shaking and choking from the severe pain she had experienced. The resident reported the pain was in her pelvis, where she had a fracture, and that the pain radiated up into her bowels causing severe discomfort. The resident reported she discussed the concern with CNA #7, to whom she initially reported her pain on the previous evening. According to the resident, the CNA had told her the facility had problems with running out of pain medication because medication refill requests were not made timely. The CNA reported the resident's pain request to licensed practical nurse (LPN) #1. The resident stated LPN #1 told her she was out of pain medication and that the pharmacy would be delivering it soon. The resident reported that no alternate pain medication was offered and staff refused to provide medication from the emergency supply kit. The resident stated she had difficulty getting her pain medications on time and often waited five to six hours between her pain medications which were ordered every four hours. The resident stated that her home pain regimen included [MEDICATION NAME], and Tylenol for her chronic pain. On 11/20/15 at 10:38 a.m., an interview with the resident's family member, conducted in the presence of the resident, revealed: The family member reported the resident had severe pain from the pelvic fracture and also had chronic pain that was being managed prior to the fall. The family member stated the resident was not getting routine pain medication when she arrived at the facility, even though the resident had taken scheduled pain relief prior to the emergency room visit and subsequent admission to the facility post-pelvic fracture. The family member reported the resident's call light was not working for the first couple of days. According to the family member, the resident phoned her so the family member could call the desk to obtain assistance for the resident. The family member had reported call light concerns to the facility at a meeting on 11/3/15. The family member stated she was aware that the resident had run out of pain medication on the overnight of 11/18 into 11/19. The family member stated the resident reported experiencing severe pain related to the missed dose of pain medication. The family member reported the resident also reported a delay in receiving scheduled medications. C. Staff Interviews On 11/20/15 at 10:15 a.m., an interview and observation with CNA with medication aide authority (CNA-Med) #1 revealed that the resident had received her current bubble pack of [MEDICATION NAME] 10 mg on 11/19/15. The CNA-Med stated she recalled hearing the resident had missed a dose overnight on 10/19/15. On 11/20/15 at 4:24 p.m., an interview with registered nurse (RN) #4, who worked evenings and overnights providing resident care revealed: The RN stated that when a resident is admitted , the nurse completes a pain risk tool to identify the resident's risk for pain using a form in the electronic record. According to the RN, this was part of the initial nursing data gathering done at admission. The RN stated that nurses also assess residents for pain level using an appropriate pain scale like a verbal pain scale for alert and oriented residents and facial/visual/audible pain scale for residents with dementia that cannot provide a numeric response. Pain scale results are recorded in the electronic record. The electronic record prompts nurses to inquire about pain routinely. The RN stated that pain levels were also checked when administering as needed (PRN) pain medications. Pain levels obtained with PRN medications were recorded in the medication administration record (MAR) at the time the medication was administered and 30 to 60 minutes after the medication was administered to verify relief. The RN stated that if a resident ran out of routine pain medication, that nurses could contact the pharmacy to obtain permission to access the emergency kit, regardless of the time of day. The RN stated it was not difficult to coordinate access to the emergency kit if the resident had an active prescription for the medication on file with the pharmacy. The RN stated that if she was unable to obtain permission to access the emergency kit, she would provide non-pharmacological approaches, contact the physician for additional instruction, and document her actions in the nurse's notes. On 11/24/15 at 1:57 p.m., an interview with CNA #3, who worked with the resident on the day shift, revealed the resident complained of pain. According to the CNA, the resident most often verbalized pain in the morning. On 11/24/15 at 2:18 p.m., an interview with CNA-Med #1, who typically provided pain medications to the resident on the day shift, revealed: The CNA-Med stated the resident was in pain all the time. According to the CNA-Med the resident often reported pain levels of eight or nine. The CNA-Med stated that the nurse was responsible for assessing resident pain, but that if a resident reported a pain level she passed this on to the nurse for follow-up. The CNA-Med stated the she would record pain levels, when directed, on the medication administration record (MAR). Review of the MAR with the CNA-Med revealed pain levels were recorded on the MAR from 11/1/15 to 11/15/15, when the resident received [MEDICATION NAME] (over the counter pain medication). The CNA-Med stated she did not know why pain levels were documented for those days and not for the remainder during resident's stay. The CNA-Med stated that if a resident ran out of a pain medication before a refill arrived from the pharmacy, she would report that to the nurse. The nurse could then obtain the drug from the emergency kit with authorization from the pharmacy. The CNA-Med stated that nurses would also access the emergency kit for pain relief for newly admitted residents because pain medication could be slow to arrive from the pharmacy. On 11/24/15 at 2:55 p.m., an interview with CNA #6, who reported working with the resident on evenings including the day of her admission, revealed: The CNA reported that the resident's call light was not working when she arrived. According to the CNA he had to replace the batteries. The CNA recalled doing this the day after the resident was admitted . The CNA stated the resident did not have pain medication when she arrived. The CNA reported that the resident was out of it and was in pain for two to three hours before her pain medication arrived from the pharmacy. According to the CNA, he knew the resident was in pain the day of admission because the resident reported being in pain. The CNA stated the resident had been sore from her fall early that day when she broke her pelvis. On 11/25/15 at 5:36 a.m., an interview with the CNA #7, who worked with the resident on the night shift, revealed: The CNA reported that the resident had pain that was really bad when she first arrived. The CNA stated the resident was able to say she was in pain but also looked like she was in pain. The CNA stated the resident's pain control improved when they added a fourth scheduled nighttime dose of APAP. The CNA reported the resident felt the APAP was necessary to relieve her pain because the [MEDICATION NAME] alone was not effective. The CNA reported the resident did run out of pain medication on the night shift that started on 11/18/15. According to the CNA, the resident was uncomfortable that night. The CNA reported the resident worried about running out of pain medication. The CNA stated that the facility did run out of pain medications and confirmed reporting that to the resident the night she ran out of pain medication. The CNA stated when pain medications were getting low, nursing staff should re-order them to ensure residents did not run out. According to the CNA, the resident's medication was not re-ordered until it ran out that night. On 11/25/15 at 5:47 a.m., an interview with licensed practical nurse (LPN) #1 revealed: The LPN stated that the resident cried in pain when she first arrived at the facility. The LPN stated it took three days for the facility to get the resident's pain under control. The LPN stated the resident did run out of pain medication for the midnight dose on 11/19/15. The LPN stated the resident became hysterical when he informed her that she did not have the scheduled midnight dose of [MEDICATION NAME] available. The LPN stated that he did not obtain a permission from the pharmacy to administer the scheduled dose from the emergency kit. The LPN stated he did not think the resident needed the midnight dose of [MEDICATION NAME], but wanted it because it was scheduled. The LPN stated the resident was meticulous about her pain medications and wanted them on time. The LPN stated he provided the resident with her next scheduled dose of [MEDICATION NAME] on 11/19/15 at around 5:00 a.m., after it arrived. On 11/25/15 at 8:17 a.m., an interview with the director of nursing (DON) revealed: The DON stated that residents at high risk for pain were assessed routinely for pain and this was documented in the vital signs portion of the electronic record. After reviewing the clinical record, the DON acknowledged the resident did not have routine pain monitoring from admission on 10/28/15 through 10/31/15 and from 11/16/15 through discharge on 11/20/15. The DON was not able to explain the absence of routine pain monitoring for the initial days after admission and prior to discharge days. The DON acknowledged the resident did not have routine pain management in place when she was admitted to the facility on [DATE]. The DON stated the resident received no doses of [MEDICATION NAME], according to the MAR, when she arrive the afternoon of 10/28/15. Review of the narcotic sheet revealed the resident did have two tablets of [MEDICATION NAME] 5/325 at 9:30 p.m. The DON stated that the resident received a physician visit on 10/29/15. At that time the physician changed the resident's pain medication from as needed [MEDICATION NAME] to scheduled [MEDICATION NAME]. The DON stated that the order allowed the facility to continue using the [MEDICATION NAME] until the [MEDICATION NAME] arrived from the pharmacy. The DON stated that the resident did miss a dose of [MEDICATION NAME] at midnight on 11/19/15. The DON stated she expected the nurse to obtain the medication from the emergency kit after contacting the pharmacy and obtaining permission. The DON stated she had educated LPN #1 about her expectations. The DON stated they did have difficulty getting re-ordered medications from the pharmacy timely. The facility was in the process of switching to another pharmacy. Pain levels in the MAR and in the vital sign documentation were reviewed with the DON. The DON acknowledged the resident had pain levels of 8-10 indicating severe pain. The DON reviewed the resident's clinical record and was unable to identify an acceptable level of pain for the resident. The DON stated she did not know what level of pain was acceptable to the resident. D. Record Review A review of the clinical record revealed the facility was not consistently monitoring the resident's pain at arrival to the facility by a systematic method. The resident did not receive pain medication from the emergency kit when ordered pain medications were unavailable. Assessment and mitigation of pain was not conducted when scheduled pain medication was not administered due to unavailability. 1. History and Physical (H&P) The 10/28/15 H and P revealed the resident had the following pain management in place prior to admission to the facility: -[MEDICATION NAME] 5/325 mg one tablet by mouth ever four hours for moderate pain. -[MEDICATION NAME] 5 mg, take 5-10 mg by mouth once daily as needed for pain. 2. Medication Administration Record (MAR) a. October 2015 The 10/2015 MAR revealed: -[MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME]) 5/325 mg Tablet: Give one tablet by mouth every four hours as needed for pain level of 1-5. Do not exceed three grams (g) of [MEDICATION NAME] (APAP) in 24 hours. The order was started on 10/28/15 and discontinued on 10/30/15. This medication order was not administered. -[MEDICATION NAME] 5/325 mg Tablet: Give 2 (two) tablet by mouth every four hours as needed for pain level of 6-10 NTE (not to exceed) 3g APAP in 24 hours. This order started on 10/28/2015 and was discontinued on 10/30/2015. The resident received the first dose of this medication on 10/29/15 at 4:54 a.m., for pelvic pain of 9 out of 10. The resident received additional doses of [MEDICATION NAME] at 9:01 a.m., for pelvic pain of 8 out of 10; at 1:43 p.m., for pelvic pain of 10 out of 10; and 6:32 p.m., for pelvic pain of 9 out of 10. -[MEDICATION NAME] 650 mg Tablet: Give 650 mg by mouth every four hours as needed for pain NTE 3 gm APAP in 24 hours. The order was started on 10/28/15 and was discontinued on 11/5/15. The resident did not receive any Tylenol in October. -[MEDICATION NAME] HCl 10 mg Tablet: Give 10 mg by mouth every four hours for pain management. The order was started on 10/29/15 at 3:15 p.m., and was discontinued at discharge on 11/20/15. The first dose was administered at midnight on 10/30. The resident did not receive [MEDICATION NAME] on 10/29. The MAR showed the resident received [MEDICATION NAME] 5/325 instead of [MEDICATION NAME] on 10/29/15 at 4:00 p.m., and 8:00 p.m. b. November 2015 - [MEDICATION NAME] 650 mg Tablet: Give 650 mg by mouth every four hours as needed for pain NTE 3 gm APAP in 24 hours. The order was started on 10/28/15 and was discontinued on 11/5/15. The medication was given seven times from 11/1/15 through discontinuation on 11/5/15. Pain levels were recorded with the administration of the medication. The recorded pain levels were: -4 on 11/4/15 at 2:05 p.m. -5 on 11/1/15 at 1:13 a.m., 10:45 p.m., and 11/3/15 at 3:19 p.m. -6 on 10/2/15 at 6:37 p.m., 10/4/15 at 1:52 a.m., and 6:25 p.m. -[MEDICATION NAME] 650 mg Tablet: Give 650 mg by mouth three times a day for pain. This medication was scheduled from 11/5/15 through 11/15/15. The medication was scheduled at 7:00 a.m., noon, and 4:00 p.m. Pain levels were recorded on the MAR each time the medication was administered. The recoded pain levels were: -11/5: 7,4,4 -11/6: 10,7,4 -11/7: 10,8,5 -11/8: x,8,9 -11/9:10,7,7 -11/10: 9,7,7 -11/11: 7,7,3 -11/12: 9,8,5 -11/13: 7,7,4 -11/14: 6,7,7 -11/15: 7,6, discontinued - [MEDICATION NAME] 650 mg Tablet: Give 650 mg by mouth four times a day for pain. This medication was scheduled from 11/15/15 through discharge on 11/20/15. The medication was scheduled at 7:00 a.m., noon, and 4:00 p.m., and bedtime. Pain levels were not recorded with the administration of this medication. -[MEDICATION NAME] HCl 10 mg Tablet: Give 10 mg by mouth every four hours for pain management. The order was started on 10/29/15 and continued through discharge on 11/20/15. A review of the MAR revealed the resident did not receive the midnight dose of [MEDICATION NAME] on 11/19/15. 3. Narcotic Sheets A review of the narcotic sheets revealed the resident had greater than four hours elapsed time with administration of scheduled [MEDICATION NAME] once on 11/8/15, 11/9/15, 11/11/15 and 11/20/15; and had more than four hours between scheduled [MEDICATION NAME] two times on 10/30/15 and 11/13/15. The narcotic sheet showed no [MEDICATION NAME] was provided from 11/18/15 at 4:00 p.m. until 11/19/15 at 4:30 a.m. 4. Nurse's Notes A 10/28/15 at 5:00 p.m., a note documented the resident expressed dissatisfaction with having to ask for pain medication. The resident requested to have her pain rate assessed every four hours. An 11/12/15 at 11:31 p.m., a note documented the resident regularly asked for 650 mg APAP at bedtime but had no as needed (PRN) order. The plan was to contact the physician for an order to provide bedtime APAP dose. (The night time dose was not obtained until 11/15/15.) A review of the nurses' notes revealed no documentation of the nurse's attempt to measure and mitigate the resident's pain on 11/19/15 when the [MEDICATION NAME] was unavailable for the 12:00 a.m. dose. 5. Pain Tracking A review of the pain tracking in the vital signs portion of the chart revealed the resident had pain tracked once to three times daily (not every four hours as requested by the resident at admission see 10/28/15 nurse's note) from 11/1/15 through noon on 11/15/15. Review of the pain tracking revealed: -The resident had pain levels recorded once daily on 11/2/15 and 11/3/15. -The pain had pain levels recorded twice daily on 11/1/15, 11/8/15, 11/9/15, 11/10/15, and 11/15/15. -The resident had pain levels recorded three times daily on 11/4/15, 11/5/15, 11/6/15, 11/11/15, 11/12/15, 11/13/15, and 11/14/15. -The resident's pain ranged from 3 to 10. The resident expressed pain of 3 one time; 4 five times; 5 five times; 6 five times; 7 eleven times; 8 three times; 9 three times and 10 three times. -Each pain level of 10and two of the three 9 pain levels were recorded in the morning between 7:00 a.m., and 9:00 a.m. No pain tracking was present in the vital sign pain tracking system from 10/28/15 through 10/31/15 and from 11/16/15 through discharge on 11/20/15. E. Emergency Kit Inventory A review of the emergency kit inventory provided by the DON on 11/25/15 revealed the traditional emergency kit included 20 tablets of 5 mg [MEDICATION NAME] and the computerized access emergency kit inventory contained both 10 mg and 5 mg [MEDICATION NAME]. II. Resident #305 Sample resident #305, age 76, admitted to the facility 11/18/15. The resident's facility face sheet identified [DIAGNOSES REDACTED]. The 11/18/15 entry MDS did not have any documentation listed related to the resident's skin condition. a. Observation: On 11/19/15 at 2:19 p.m., the resident had bruises observed on both forearms and the top of her left hand. On 11/24/15 at 11:31 a.m., the resident's right forearm was observed with a cluster of multiple bruises. There were approximately five to six bruises of varying size and discoloration. There was a bruise on the resident's left arm between the resident's forearm and bicep. The bruise was light in color. b. Record Review: 1. Care Plans The resident's 11/19/15 skin care plan showed the resident had potential/actual impairment to skin integrity related to surgical incision to left hip. -The goal was the resident would not have any complications related to skin injury type (left hip incision) through the review date. -Some of the interventions consisted of: monitor for side effects of the antibiotics and over the counter pain medications, gastric distress, rash, or allergic reactions which could exacerbate skin injury; monitor/document locations, size and treatment of [REDACTED]. The care plans further showed the resident was on two anticoagulant medications for post surgery and heart health. Some of the listed interventions were daily skin inspections and review of abnormalities and side effects such as bruising. 2. Skin Assessment The 11/18/15 admission skin tool showed the resident had bruising noted to both upper extremities at forearms and upper arms. The note stated the bruises were needle stick bruises. There was no further documentation about how many bruises were on the resident's arms, the size of the bruises, or color. The 11/19/15 daily skilled documentation failed to show any documentation related to the bruising observed on the resident's forearms although it was identified on 11/18/15. In the skin section, the facility noted the resident had an incision from surgery. c. Interviews: On 11/24/15 at 10:11 a.m., a certified nurse aide (CNA) #2 said she looked for resident skin conditions and reported any discoloration and skin tears to the nurse. The CNA stated any unusual skin conditions were also reported. The CNA stated the resident may have some bruising from surgery but she was not aware of any skin bruising on the resident's forearms. On 11/24/15 at 11:40 a.m., a licensed practical nurse (LPN) #2 stated when residents were admitted into the facility, head to toe checks were conducted. The LPN reported staff was to look for any open skin areas, skin breakdown, discoloration, deep tissue injuries. She stated staff also looked at redness and bruising. The LPN reported sometimes staff would map the locations of areas of the body where skin concerns were observed. She stated knowing about the color, location, size, and amount allowed for people to know no new bruising, blood clotting, or bleeding issues were occurring. The LPN reviewed the resident's record and confirmed the admission skin assessment did not report how many bruises were on the resident's forearms, the size, measurement, or color. The LPN stated the resident was on two anticoagulants, blood thinner medication. On 11/24/15 at 3:02 p.m., the director of nursing (DON) expressed the documentation for the bruising on the resident's forearms should have been more specific with measurement sizes and color. She said having more detailed information allowed staff to determine if there was new bruising, if the bruises were healing or getting worse. The DON acknowledged the facility body map had options to specify location, size, and comment on the skin concerns: however, staff had not used the body map when describing the resident's skin condition. d. Facility Follow-up: On 11/24/15 at 11:50 a.m., LPN #2 confirmed the resident had a cluster of bruising on her left forearm and her right forearm had a healing bruise between her inside forearm and bicep.