Every finding on record at Suites at Holly Creek Care Center, The

Based on observations, record review and interviews, the facility failed to ensure one (#6) of one resident reviewed for pressure injuries out of 20 sample residents received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #6 was admitted on [DATE] for long term care. At the time of admission, the resident was identified for being at risk for developing pressure injuries. Upon admission, the resident had a surgical incision on her right leg and her skin was otherwise intact. Resident #6 attended dialysis three times a week. On 8/2/24, a primary care physician documented Resident #6 developed a blister on her left heel that had thick white drainage which may have represented some early infection. Preventative measures to protect the resident's heels were not implemented until after the development of the blister on 8/2/24. On 9/6/24, a physician's progress note documented the resident's left heel had developed eschar (dead tissue). On 11/7/24, when the wound care physician took over care (three months after the blister was initially identified), the wound was classified as an unstageable ulcer to the left heel. Due to the facility's failure to implement effective pressure injury interventions in a timely manner, Resident #6 developed a facility-acquired unstageable pressure injury to her left heel. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved on 11/24/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Pressure Injury Prevention and Management policy and procedure, revised November 2022, was received from the nursing home administrator (NHA) on 11/21/24 at 2:46 p.m. It documented in pertinent part, The purpose of the policy is to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries. Preventative interventions can be, but are not limited to, frequent position changing and support of pressure points, adequate hydration and nutrition, appropriate exercise and movement, frequent perineal care, proper lifting techniques, correct application of pressure relieving devices and frequent inspection and assessment of skin integrity. Compliance with interventions will be documented in the medical record. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. A key implementation to pressure ulcer management will be interdisciplinary team (IDT) involvement and review and comprehensive care planning. III. Resident #6 A. Resident status Resident #6, age 73, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included diabetes mellitus (high blood sugar), end stage kidney disease (kidneys can no longer support body's needs) with hemodialysis (process where a machine filters and cleans the body's blood), right below the knee amputation and peripheral vascular disease (narrow blood vessels). According to the 10/19/24 minimum data set (MDS) assessment, Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required substantial/maximal assistance for showering/bathing, dressing and transferring. She was independent with wheeling in her motorized wheelchair. The MDS assessment documented that the resident was at risk of developing pressure ulcers and had one unstageable pressure ulcer due to the coverage of the wound bed by slough (soft, dead tissue, usually cream or yellow in color) and/or eschar. B. Resident interview Resident #6 was interviewed on 11/18/24 at 2:53 p.m. Resident #6 said the wound to her left heel developed at the facility and the facility staff were not floating the heel or using the blue botties prior to it developing. She said the heel wound started as a blister. C. Wound observation and interview On 11/20/24 at 2:10 p.m., a wound observation was completed with the assistant director of nursing (ADON). Resident #6 was positioned in her motorized wheelchair. The resident was wearing a soft blue bootie on her left foot. With consent from the resident, the ADON removed the dressing to the resident's left heel. Moderate light brown drainage was observed on the dressing. The wound on the resident's heel was round in shape, covering the entire heel. The wound was covered in black tissue (eschar), obstructing the wound. The periwound (skin surrounding the wound) was red. The ADON said there was stable eschar covering the wound. She said the periwound was red. She said there was little to no drainage. She said she had been tracking the wound since it started as a blister. She said at first it was cellulitis and the resident was started on an antibiotic. D. Record review The admission Braden scale for predicting pressure sore risk was completed on 7/15/24. It documented Resident #6 had a score of 18 which indicated she was at risk for developing pressure ulcers due to being chairfast, having slightly limited mobility, not having adequate nutrition and a potential problem for friction and shear. The skin integrity care plan, initiated 6/12/24 and revised 8/30/24, identified the resident had actual impairment to skin integrity with a right below the knee amputation and a left heel open blister. The care plan documented Resident #6 chose to remain in her wheelchair for long periods of time despite the potential risk of skin breakdown attributed to prolonged immobility (added 8/30/24). Interventions included cellulitis identified with pitting edema causing a blister. Treatment initiated. Prevelon boot (soft blue boot) ordered for offloading therapy (initiated 8/2/24), avoiding scratching and keeping hands moist and keeping fingernails short, educating caregivers and the resident of causative factors and measures to prevent skin injury (initiated 6/21/24), following facility protocols for treatment (initiated 8/13/24), using booties at night for skin integrity (initiated 8/6/24), providing a pressure-redistributing bed with a pump to prevent pressure ulcers due to her immobility (initiated 8/30/24) and monitoring/documenting location, size and treatment of skin injury and reporting abnormalities, failure to heal, signs and symptoms of infection or maceration to the physician (initiated 6/21/24). Review of Resident #6's November 2024 CPO revealed a physician's order to float the resident's heel when in bed, ordered 8/2/24. -However, review of the resident's August 2024 treatment administration record (TAR) revealed there was no documentation of the left heel being offloaded until 8/6/24, four days after the wound was identified and the above physician's order was obtained. A note from the vascular surgeon on 9/30/24 documented a follow up appointment Resident #6's left heel wound. The note documented the resident had adequate blood flow to her left lower leg. The wound care physician's (WCP) progress note from 11/21/24 documented Resident #6's left heel wound was an unstageable pressure wound due to necrosis (dead tissue). It was documented that there was moderate serous exudate (clear to light yellow fluid leaking from the wound) with 90% thick adherent devitalized necrotic tissue and 10% slough (shedding). IV. Staff interviews Certified nurse assistant (CNA) #4 was interviewed on 11/20/24 at 2:30 p.m. CNA #4 said Resident #6 had a wound to her left heel. She said she required one staff member's assistance for dressing, bathing and transferring with a slide board. She said on the days the resident went to dialysis, she required two people for assistance because staff used the hoyer lift so she had a sling under her body for transferring at dialysis. CNA #4 said Resident #6 never refused care. The director of nursing (DON), the ADON and the NHA were interviewed on 11/20/24 at 3:00 p.m. The DON said Resident #6 was readmitted on [DATE] after a right below the knee amputation. She said the resident was weight-bearing as tolerated and working with therapy. She said the resident scored a mild risk for pressure injury development on her admission Braden scale, so additional interventions were not put into place. She said on the Braden scale from 7/29/24, she scored a moderate risk so an intervention for a wheelchair cushion was added to help prevent pressure injury to her bottom. The DON said Resident #6's left heel blister was identified on 8/2/24 and a Prevelon boot (protective boot) was ordered. She said there was an order to offload the resident's heel until the boot came in on 8/6/24. She said the boot was not appropriate for the resident prior to the development of the wound because she was working with therapy and was weight-bearing as tolerated. She said she was wearing a regular shoe prior to the development of the heel blister. The DON said once the eschar formed on the wound and it was deteriorating, a pressure-reducing mattress was ordered on 8/30/24. The DON said Resident #6's vascular surgeon and the resident's primary care physician were managing the left heel wound initially. She said the WCP began to manage the wound on 11/7/24 (three months after the development of the wound). The WCP was interviewed on 11/21/24 at 12:00 p.m. The WCP said Resident #6's left heel wound was an unstageable ulcer with 100% necrotic eschar that had been stable for the past three weeks, since she had taken over her wound care management. She said the first week, on 11/7/24, when she saw Resident #6, there was no drainage to the wound. She said on 11/21/24 there was moderate serous drainage. The WCP said since the wound had deteriorated, she did a small debridement on 11/21/24 and talked to Resident #6 about ordering a different style of boot that would offer more protection to the heel. She said the wound was caused by pressure between the foot and the bed or chair. She said the resident had multiple comorbid factors which included diabetes type two, peripheral vascular disease and neuropathy that were likely all contributing factors to the development of the wound. She said offloading the heel was always a beneficial intervention for pressure injury prevention.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure staff donned (put on) appropriate personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions (EBP); and, -Ensure staff followed appropriate infection control practices while cleaning resident rooms. Findings include: I. Failure to ensure staff donned appropriate PPE when providing care to a resident on EBP A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Frequently Asked Questions (FAQs) About Enhanced Barrier Precautions (EBP) In Nursing Homes (6/28/24) retrieved on 11/12/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html, EBP are an infection control strategy that involves wearing gowns and gloves during high-contact resident care activities. Enhanced Barrier Precautions are recommended for residents with any of the following: infection or colonization, or a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a multi drug resistant organism (MDRO). B. Facility policy and procedure The Enhanced Barrier precautions policy and procedure, revised July 2024, was received from the nursing home administrator (NHA) on 11/20/24 at 12:50 p.m. It documented in pertinent part, EBP are an infection control intervention designed to reduce the transmission of resident organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated for residents with any of the following: wounds, indwelling medical devices and infection or colonization with a multi-drug resistant organism. Examples of high contact resident care activities requiring gown and gloves use for EBP include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care and wound care. C. Observations On 11/20/24 at 9:20 a.m., certified nursing assistant (CNA) #2 was completing catheter care for Resident #20. The sign on the cabinet in the resident's room indicated the resident was on EBP and the required PPE included wearing gloves and a protective gown when performing high contact direct resident care. CNA #2 washed her hands, applied clean gloves and proceeded to complete catheter care for the resident. -CNA #2 did not put a protective gown on prior to entering Resident #20's room and performing catheter care. D. Staff interviews CNA #4 was interviewed on 11/20/24 at 2:30 p.m. CNA #4 said when she was providing care to residents with catheters, she would wear gloves for any care she provided. She said she would only wear a gown if the resident was on contact precautions. The infection preventionist (IP) was interviewed on 11/21/24 at 11:50 a.m. She said chronic wounds, foley catheter, and any open lines qualified a resident to be placed on EBP. She said CNA #4 should have followed the appropriate PPE recommendations and donned a gown prior to performing catheter care for Resident #20. II. Failure to ensure staff followed appropriate infection control practices while cleaning resident rooms A. Professional reference According to the CDC Recommendations for Hand Hygiene for Healthcare Workers, (2024), retrieved on 11/26/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, CDC provides the following recommendations for hand hygiene in healthcare settings. Know when to clean your hands: after touching a patient's surroundings, immediately after gloves removal. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised November 2022, was received from the regional director of clinical services (RDCS) on 11/21/24 at 12:17 p.m. It documented in pertinent part, the community considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene includes both hand washing and the use of alcohol-based hand sanitizer. The use of gloves does not replace hand hygiene. C. Observations During a continuous observations on 11/20/24, beginning at 8:20 a.m. and ending at 9:15 a.m., the following was observed: Housekeeper (HSKP) #2 was observed cleaning resident room [ROOM NUMBER]. She donned clean gloves and sprayed down all high touch surfaces. She removed the gloves and without sanitizing her hands, donned clean gloves. She wiped down all the surfaces in the bedroom and bathroom and sprayed the shower with water. She removed her gloves and without sanitizing her hands, donned clean gloves. She swept the bathroom and entry way and mopped the bathroom and entry way. She dusted the shelves, vacuumed the bedroom and changed the trash. She removed her gloves and without sanitizing her hands, donned clean gloves. She moved her cart down the hall. HSKP #1 was observed cleaning resident room [ROOM NUMBER]. She was in the middle of cleaning with just mopping left to complete. She removed her gloves and without sanitizing her hands, donned clean gloves. She mopped the bathroom and entry way. D. Staff interviews The IP was interviewed on 11/21/24 at 11:50 a.m. The IP said the staff should complete hand hygiene to be completed prior to and after glove removal. The environmental services coordinator (ESC) and the RDCS were interviewed together on 11/21/24 at 11:45 a.m. The ESC said the expectation for housekeepers cleaning resident rooms was to change gloves between cleaning each room, which included the kitchen, bedroom and bathroom. She said there would be at least three gloves changes and she would expect hands to be sanitized after each glove removal.

Based on observations, record review and interviews, the facility failed to ensure two (#4 and #10) of two of 20 sample residents remained free from accidents hazards. Specifically, the facility failed to ensure Resident #4 and Resident #10 had a physician's order, a consent and a completed safety assessment before the implementation of a floor to ceiling transfer pole by the resident's bed. Findings include: I. Facility policy and procedure The Bed Mobility Devices policy, approved October 2024, was provided by the nursing home administrator (NHA) on 11/20/24 at 10:30 a.m. The policy revealed bed mobility devices had the potential to cause actual harm or entrapment to residents. The facility would follow the recommendations and guidelines as outlined to ensure resident safety and the appropriate use of the devices. Residents considered for a bed mobility device must be evaluated by physical therapy for safety and benefit. This therapy evaluation included an evaluation for safety as well as a discussion of the risk versus the benefits waiver and a consent. The safety evaluation included the resident's physical ability, cognition and ability to understand the education. II. Resident #4 A. Resident status Resident #4, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included dementia, muscle weakness, atrial flutter (fast heart rate), abnormalities of gait and mobility. The 8/17/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. The resident required partial/moderate staff assistance to sit to stand (ability to come to a standing position from sitting in a chair, wheelchair or on the side of a bed) and chair/bed to chair transfer (ability to transfer to and from a bed to a chair or a wheelchair). B. Resident observations On 11/18/24 at 12:34 p.m. a floor to ceiling transfer pole was observed beside the resident's bed and near the resident's recliner. The resident was sitting in a recliner across from the bed. On 11/19/24 at 1:39 p.m, a floor to ceiling transfer pole was observed beside the resident's bed and near the resident's recliner. The resident was sitting in a recliner across from the bed. On 11/20/24 at 12:50 p.m., a floor to ceiling transfer pole was observed beside the resident's bed and near the resident's recliner. The resident was sitting in a recliner across from the bed. The transfer pole by the bed measured eight inches away from the bed frame, toward the center of the room. C. Record review A fall risk assessment dated [DATE] at 11:37 p.m. revealed a score of 12.5 which indicated the resident was a high fall risk. The care plan for activities of daily living (ADL) self-care performance deficit was revised on 4/30/24. The pertinent interventions included providing extensive staff assistance for transfers. One staff member was to provide assistance to move the resident between surfaces. The resident had a transfer bar (pole) located adjacent to the bed and recliner. A review of the resident's electronic medical record (EMR) on 11/20/24 did not reveal a physician's order for the use of a transfer pole, the assessment or the consent. III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included diaphragmatic hernia, retention of urine, long term use of an anticoagulant and an acute embolism and thrombosis of the deep veins of the left lower extremity. The 11/2/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident required substantial/maximal staff assistance to sit to stand and chair/bed to chair transfer. B. Resident observations and interview On 11/18/24 at 12:51 p.m. a floor to ceiling transfer pole was observed beside the resident's bed and a second transfer pole was near the resident's recliner. On 11/19/24 at 11:17 a.m. a floor to ceiling transfer pole was observed beside the resident's bed and a second transfer pole was near the resident's recliner. The resident was sitting in the recliner and said he used both transfer poles to help him stand up. On 11/20/24 at 12:40 p.m. a floor to ceiling transfer pole was observed beside the resident's bed and a second transfer pole was near the resident's recliner. The resident was sitting in the recliner. The transfer pole by the bed measured five inches away from the bed frame, toward the center of the room. C. Record review A fall risk assessment, dated 11/1/24 at 2:54 p.m., revealed a score of 10.5 which indicated the resident was at high fall risk. The care plan for ADLs self-care performance deficit was revised on 7/31/24. The pertinent interventions included the resident required extensive staff assistance for transfers. Two staff were to provide assistance to move the resident between surfaces. -The care plan did not reveal the resident utilized transfer poles. A review of the resident's EMR on 11/20/24 did not reveal a physician's order for the use of a transfer pole, the assessment or the consent. IV. Staff interviews The director of rehabilitation (DOR) was interviewed on 11/20/24 at 2:03 p.m. The DOR said there was no official transfer pole assessment for either resident, prior to the installation of the transfer poles. She said the transfer poles would be placed by each resident's bed frame so that the pole could be used by the resident to assist with transfers and a sufficient distance from the bed frame so that entrapment did not occur. The NHA and the director of nursing (DON) were interviewed on 11/21/24 at 11:40 a.m. The NHA said Resident #4 was a high fall risk. The NHA said the resident had no falls nor any injuries related to the use of a transfer pole. The NHA said that physical therapy did not do an official transfer pole assessment prior to the installation of either of the transfer poles in the resident's room on 10/14/24. The NHA said the ability or the functionality of each resident, determined the distance the transfer pole was positioned adjacent to the bed frame. The NHA said the resident's beds were always in a locked position and the relative distance to the transfer pole remained the same. The NHA said the physician's order and consent for the transfer poles were obtained on 11/19/24 (during the survey). The NHA said the resident's transfer pole assessment was completed by physical therapy services on 11/20/24 (during the survey). The NHA said the sequence for the use of a transfer pole was to obtain a physician's order, complete the safety assessment, obtain a consent from the resident or their legal representative and then the installation of the device. The NHA and the DON were interviewed together on 11/21/24 at 12:06 p.m. The NHA said Resident #11 had good cognition and good upper body strength. She said the resident used the transfer poles and had not had any issues with them. The NHA said the physician's order and consent for the transfer poles were obtained on 11/19/24(during the survey). The NHA said the resident's transfer pole assessment was completed on 11/20/24 (during the survey). V. Additional provided documents (during survey) A physician's order dated 11/19/24 at 5:57 p.m. (during the survey) revealed to place a transfer pole next to Resident #4 and Resident #10's bed and recliner. The staff were to check the placement and secure the transfer poles. The staff were to notify environmental services if the devices needed adjustments for every day and night shift for mobility. A Transfer Pole consent and release form was signed by the Resident #4 and Resident #10 on 11/19/24 (during the survey). A transfer pole assessment for Resident #4 and #10 was completed by the DOR on 11/20/24 at 8:52 p.m. (during the survey). The assessment did not reveal any concerns with the resident using transfer poles.

Based on record review, observations, and interviews, the facility failed to ensure the resident environment was as free of accident hazards (risks) as possible for three of seven residents (#22, #13 and #2) investigated for accidents and four of seven residents (#20, #16, #3 and #12) investigated for falls out of 22 sample residents. Specifically: Record review, observations, and interviews revealed the facility failed to identify, consider and address potential risks in the staff's transport of residents in wheelchairs and in the staff's transfer of residents with severe cognitive and functional limitations, in order to reduce the risks as much as possible. -Record review and interview revealed staff transported Resident #22, severely cognitively impaired and at high risk for falls, from the dining room to the TV room in her wheelchair without foot pedals (footrests) on 7/16/23. The resident's feet were caught on the floor under her wheelchair, causing the resident to fall face-forward to the floor. The resident sustained multiple injuries including bilateral nasal bone fractures, septal bone fracture (the nasal septum is a bony and cartilaginous structure located in the rough midline of the nose, which separates the right nostril from the left nostril), along with multiple cervical spine fractures. She remained in the hospital for four days and upon her return to the facility, she began receiving hospice services. -Observations on 7/24/23 revealed staff transported Resident #13 in her wheelchair without footrests, tipping the front wheels up and telling the severely cognitively impaired resident to keep her feet up. There was no evidence the facility had considered ways to minimize the risk this posed to the resident. -Record review revealed one staff transferred Resident #2 to her wheelchair using a sit-to-stand lift. The resident slid from the sling and was lowered to the floor. At the time, the resident was care planned (5/17/23), as dependent, 2 staff to move between surfaces and lifted mechanically. Although the facility investigation concluded the sit-to-stand lift was no longer appropriate for the resident, staff continued to use it. In addition, the facility failed to implement effective fall interventions for Residents #20, #16, #3 and #12. Findings include: I. Facility policy The Fall Prevention and Management policy, dated 11/2022, was provided by the nursing home administrator (NHA) on 7/27/23 at 6:00 p.m. It read in part: -The purpose of the fall prevention and management program is to identify residents and areas at risk for falls, initiate interventions to prevent and respond to falls and thus reduce the risk of injury due to falls . It is the goal of the Community and the responsibility of all associates to prevent falls in all areas of care and service. -Possible fall prevention interventions include but are not limited to fall risk assessment, low bed, fall mat, appropriate foot wear, intentional rounding, education to residents and families, life enrichment activities focused on strengthening and balance, environmental assessment to keep it clean and free of clutter/hazards, person centered fall intervention care planning, referral to rehab services, quality improvement projects, environmental safety rounding .wheelchair positioning, toileting plan . increased need for supervision . and so forth. II. Resident failures The facility failed to identify, consider and address potential hazards in the staff's transport of Residents #22 and #13 in wheelchairs, and in the staff's transfer of Resident #2 in order to reduce the hazards as much as possible. All three residents were severely cognitively impaired and required extensive staff assistance. A. Resident #22 1. Resident status a. Record review Resident #22, age 80, was admitted to the facility on [DATE]. According to July 2023 computerized physician orders (CPO), diagnoses included diffuse traumatic brain injury with loss of consciousness, traumatic brain injury, frontal lobe and executive function deficit following cerebral infarction, osteoporosis, and dementia with agitation. The 6/21/23 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of 3 out of 15. The MDS noted no hallucinations, delusions, or other behaviors. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Section J indicated the resident had two falls with no injury since the prior assessment. She received an antidepressant medication daily. The comprehensive care plan, dated 12/19/22 and 3/9/23, revealed the resident was at high risk for falls. It read in part: -I am high risk for falls. Goal: I will be free of minor injury through the review date. Safety measures will be maintained to prevent or lessen any injury from a fall. Interventions included encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate me, my family, my caregivers/IDT (interdisciplinary team) as to causes. (Dated 12/19/22) - I am a fall risk and will need somebody with me. I need assistance with my wheelchair. Sometimes I need prompting to remind me what to do next. (Dated 3/9/23) Fall risk assessments dated 3/16 and 6/30/23 scored the resident at 10 - high risk for falls. b. Observation On 7/24/23 at 12:10 p.m., Resident #22 was in the dining room. She sat in a Broda wheelchair (an elevated specialty wheelchair with adjustable tilt, recline, and footrests angle). She had a large, approximately three inches in diameter, bluish discolored bruise around her right eye, a large, approximately two inches in diameter, bluish discolored bruise around her left eye, and a goose egg size facial hematoma above her nose and the left eye with red, blue and yellowish skin discoloration. The resident kept her eyes closed during the lunch meal. 2. Fall 7/16/23 Interview and record review revealed the resident was in the hospital from 7/16/23 to 7/20/23, following a fall with multiple injuries at the facility. The resident began receiving hospice services on her return to the facility on [DATE]. a. Family interview On 7/24/23 at 5:02 p.m., Resident #22's son and daughter were interviewed. The resident's daughter participated in the interview by phone. -The resident's daughter said on 7/16/23, her father called her around midnight and said her mom was sent to a hospital after a fall with injuries. He said the staff was taking her mother from the dining room to the TV room after dinner and her foot caught under the wheelchair and she fell face down to the floor. She said the staff transported her mother without the footrests. She said as a result of her fall and all of the fractures, We had to put our mom on hospice care. She said she observed the staff was taking her mother frequently in her wheelchair without the footrests. -The resident's son said his mother was a high fall risk, that she had fallen with injuries in her apartment, and had a few falls in the facility after admission. He said she was unable to walk and required staff assistance with all transfers. b. Incident report and interdisciplinary notes 7/16/23 The 7/16/23 incident report read, Around 17:45 (5:45 p.m.) resident was (being) wheeled from the dining room with her legs up moving toward the community lounge when her legs dropped and caught on the floor under her wheelchair, in the hallway close to the nurse station. Resident fell face forward off her wheelchair. Wheelchair pedals (footrests) are not utilized as she self-propels and to avoid fall risk with self-transfers in the past. Interdisciplinary notes revealed a nurse documented an assessment of the resident's condition on 7/16/23 at 6:42 p.m. The note read, Assessment include(s) cranial nerve check, sensation, cognitive changes, pain, skin pallor, circulation: resident is A&O (alert and oriented to self), C/O (complained of) pain, unable to explain where she was hurting. -Other Observations: resident bleeding through the nostrils, nose bridge swollen and a huge hematoma formed immediately on the L (left) side of the forehead . ROM (range of motion) to all four extremities at baseline. -Interventions: Ice used on the hematoma and cold towels used to stop the nose bleed, face cleaned and bleeding well controlled. -Evaluation/Summary: Resident kept on the floor until the paramedics came to take her to the hospital for further evaluation. c. Hospital Records Hospital records revealed the resident sustained multiple injuries, including facial swelling and bruising, large anterior frontal scalp hematoma, bilateral nasal bone fractures, and septal bone fracture, along with multiple cervical spine fractures. 3. Facility Response a. Record review Record review revealed the facility completed a Risk Management review of the incident and initiated foot pedal (footrest) training, conducted a fall risk assessment of the resident, and updated the resident's care plan. -The 7/17/23 Risk Management note review read, A resident who was care planned to not use foot pedals (footrests) to promote self-propelling and prevent falls, was being pushed in a wheelchair and her feet became entangled under her, causing her to fall forward. She went to the hospital and suffered a broken nose, broken ligaments, and fractured cervical bones. She is back to the community on hospice. Foot pedal (footrest) training was initiated and completed for care partners and nurses. An audit to determine who uses foot pedals (footrests) and how they are best used for preference and independence is noted. Care plans updated based on the audit. To purchase new foot pedals (footrests) for anyone who needs them. -The 7/21/23 fall risk assessment revealed the resident again scored 10 - high risk for falls -The resident's care plan was updated to read, I have had an actual fall in the last quarter: confusion, unaware of safety needs, unsteady gait/balance problems. Actual fall with minor injury (bruising) on 7/14/23. Actual fall with major injury (nose and cervical fractures) on 7/16/23. Interventions included: Ask husband if visits can be done in common areas for increased supervision and assistance. Will offer to assist resident to go upstairs for supervised visit with husband as the walk down here for husband is very tiring. For no apparent acute injury, determine and address causative factors of the fall at the time of fall and during follow-up fall rounds. For unwitnessed falls or falls with head impact, please conduct neurovitals for 72 hours according to policy. Notify physician if there has been a change noted. Note: use of anticoagulants creates significant risk for serious injury. Provide activities that promote exercise and strength building where possible. Provide 1:1 (one on one) activities if bedbound. Resident transported to hospital for evaluation. Resident admission to hospice care on 7/20/23. Broda chair ordered and in community for support and mobility. b. Staff interviews Staff interviews confirmed the events on 7/16/23 that led to the resident's fall with injury, the resident's non-use of foot pedals (footrests), and the staff education that followed on 7/17/23. -Licensed practical nurse (LPN) #2 was interviewed on 7/25/23 at 5:40 p.m. about the resident's fall on 7/16/23. She said a certified nurse aide (CNA) was taking Resident #22 in a wheelchair from the dining room to the TV room. She said right before the TV room entrance (approximately 10 feet before the entrance), the resident's feet went under the wheelchair and the resident fell forward on her face. She said the wheelchair did not have a footrest. She said Resident #22 did not use footrests as she wheeled herself in her wheelchair backward using her feet. She said she did not see the resident propelling her wheelchair forward. She said when staff pushed the resident in her wheelchair, they asked the resident to keep her feet up. She said the director of nursing (DON) provided education to all staff the next day (7/17/23) on how to transport residents safely within the facility. Licensed practical nurse (LPN) #3 was interviewed on 7/27/23 at 3:00 p.m. She said the incident on 7/16/23 happened while a CNA pushed Resident #22 in her wheelchair from the dining room to the TV room after dinner. She said the CNA was new to the facility and did not know the resident. CNA #4 was interviewed on 7/27/23 at 3:04 p.m. He said Resident #22 was not using the footrests on her wheelchair because she was able to propel/push her wheelchair with her feet backward around the unit. -The nursing home administrator (NHA) was interviewed on 7/26/23 at 12:20 p.m. and 7/27/23 at 5:15 p.m. She said Resident #22 liked her feet on the floor/ground and propelled the wheelchair around. She said the resident was standing up from the wheelchair on her own and the foot pedals would be an obstacle and pose an additional risk for a fall. She said the CNA involved in the incident was new to the facility, working on an as-needed basis, and had been terminated. She said she conducted a full investigation related to the incident and education on wheelchair safety had been provided to the CNA as well as all care partners and nurses. She said the interdisciplinary team was auditing residents' transport after meals. 4. Facility failures a. Review of Resident #22's care plan, prior to and after her fall on 7/16/23 (see above) revealed it did not reference the resident's lack of wheelchair footrests for self-propelling, despite the Risk Management review's reference that this was care planned. Further, record review revealed no evidence the facility had identified or attempted to minimize the risk the lack of footrests posed to a severely cognitively impaired resident who required extensive assistance; these factors created the potential that the resident, when being transported by staff, would be unable to 'keep her legs up.' There was no evidence that the facility considered instructions to staff, on the care plan or the CNA task list, to apply footrests during staff transport and to remove footrests when the resident was self-propelling, and alerting new staff and staff unfamiliar with the resident of the resident's limitations that placed her at risk for a fall from the wheelchair. b. Review of the training provided by the DON and the NHA revealed it failed to address the transportation of residents with severe cognitive deficits who required assistance with all activities of daily living. A review of the training documents revealed staff was instructed to ensure the resident has foot pedals (footrests) on or is able to hold feet up .keep attention on resident while moving. However, the training failed to include the circumstances of Resident #22's fall and ways to balance the need of residents to self-propel and maintain their independence with the need for safety when being transported by staff. Observations of staff transport of Resident #13 (see below) on 7/24, 7/25, and 7/26/23, revealed the facility training on 7/17/23 had not been adequate to address potential risks Resident #22's transport had disclosed. B. Resident #13 1. Resident status Resident #13, age 96, was admitted to the facility on [DATE]. According to July 2023 CPO, diagnoses included Alzheimer's disease, atherosclerotic heart disease, and dementia. A 6/1/23 Social Services Quarterly Summary read, in part, that the resident required extensive assistance for all activities of daily living and is generally non-verbal. She utilized a wheelchair for mobility and required her care team to push/transfer her. A 6/16/23 MDS assessment revealed the resident had unclear speech and rarely/never was able to understand others. She had short and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. She had no hallucinations, delusions, or rejection of care behaviors. She was totally dependent on one staff with bed mobility, totally dependent on two staff with transfers, she required extensive assistance from one staff with dressing, eating, and personal hygiene, and extensive assistance from two staff with toilet use. She had lower extremity range of motion (ROM) impairment on both sides. She used a wheelchair for mobility. She had no falls. 2. Facility failures a. Resident observations on 7/24/23 revealed staff transported Resident #13 in her wheelchair without footrests, tipping the front wheels up and telling the severely cognitively impaired resident to 'keep her feet up.' On 7/24/23 at approximately 10:20 a.m., observation revealed CNA #2 transporting Resident #13 from outside the facility to the neighborhood/unit in a wheelchair. There were no footrests on the wheelchair. The CNA lifted the front wheels of the wheelchair up and told the resident to keep her feet up. He then lowered the front wheels to the ground and kept telling the resident, repeating several times, Keep your feet up, just keep your feet up as they proceeded to the unit. The facility entrance security video camera footage dated 7/24/23 at approximately 10:20 a.m. (stamped on the camera 9:20 a.m. - time was not adjusted after the spring time change) was reviewed on 7/26/23 at 11:00 a.m. in the presence of the NHA and the executive assistant. It showed staff (CNA #2) taking Resident #13 from outside to the unit. The resident's legs were on the ground, crossed. The CNA lifted the front of the wheelchair so the resident's legs were above the ground and started wheeling the resident into the facility. At 11:20 a.m., the NHA, after viewing the video camera footage, said the CNA should not tip the wheelchair front up and should have footrests on the wheelchair when transporting the resident. Observations of Resident #13 throughout the day, before and after meals, on 7/24/23, 7/25/23, and 7/26/23 revealed nursing staff transported the resident in her wheelchair from her room to the dining and then to the TV/activities room without footrests. On 7/26/23 at 12:15 p.m., Resident #13 sat in her wheelchair in the dining room. Her feet were on the floor and her legs crossed. At 1:02 p.m., a CNA pushed the resident in her wheelchair from the dining room to the TV/activities room. The resident's legs stretched out and she held her feet above the floor. No footrests were on the wheelchair. The CNA kept telling the resident to keep her feet up. b. Staff interviews revealed conflicting understanding of the resident's non-use of footrests. It also revealed no attempts prior to the survey to consider ways to minimize the risk the lack of foot pedals posed for a cognitively impaired resident with functional limitations when being transported by staff. On 7/26/23 at 12:20 p.m., the NHA said Resident #13 liked to propel her wheelchair around with her feet on the ground. However, observations of Resident #13 throughout the day on 7/24/23, 7/25/23, and 7/26/23 did not reveal the resident at any time propelling her wheelchair independently (see above) and staff interview indicated a different reason that the resident was not using footrests. CNA #2 was interviewed on 7/26/23 at 1:45 p.m. He said Resident #13 had the wheelchair footrests in her room. He said the staff did not use them on Resident #13's wheelchair because she always kept her legs stretched out and crossed and her feet would not stay on the footrests. Record review revealed the facility had not considered ways to keep the resident's feet on the foot pedals to minimize the risk the lack of foot pedals posed for the [AGE] year-old, severely cognitively impaired resident with functional limitations when being transported by staff. The DON was interviewed on 7/26/23 at 1:48 p.m. She said the facility had just started looking at a durable medical equipment catalog for a purchase of a device/cover on the wheelchair footrests for Resident #13. 4. Facility follow-up Resident #13 was observed on 7/26/23 at 3:03 p.m. in the TV room. She was in her wheelchair with her feet on the footrests. On 7/26/23, the facility provided additional staff training on safety during wheelchair mobility; specifically, that wheelchair should never be tilted backwards. C. Resident #2 1. Resident status Resident #2, age 101, was admitted on [DATE]. According to July 2023 CPO, diagnoses included Parkinson's disease, insomnia, dysphagia, oropharyngeal phase, and dementia. The 5/17/23 significant change MDS assessment revealed the resident had unclear speech and sometimes was able to understand others. Section C Cognitive Patterns did not reflect the resident's cognitive status. No hallucinations, delusions, or rejection of care were noted. She required extensive assistance from two staff with bed mobility and transfers, and extensive assistance from one staff with dressing, eating, and personal hygiene. She was totally dependent on staff for toilet use. She was unable to walk and used a wheelchair for mobility. She did not receive scheduled or PRN pain medications. She had no falls since the prior assessment. No medications to administer. The 3/8/23 MDS assessment, section C revealed the resident was rarely/never understood, had short and long-term memory problems, and her cognitive skills for daily decision-making were severely impaired. The comprehensive care plan review revealed in part, -I have an ADL (activities of daily living) self-care performance deficit r/t (related to) Parkinson's disease. (Date Initiated: 2/20/2018.) Interventions included: -I have impaired cognitive function/dementia or impaired thought processes. Parkinson's disease/dementia. (Date Initiated: 4/4/2018) -I am high risk for falls r/t (related to) to my balance, and poor safety awareness, Parkinson's disease, hx (history) of falls, side effects from medication. (Date Initiated: 2/20/2018). 2. Fall 6/6/23 Interdisciplinary notes -On 6/6/23 a nurse documented: Writer received report that resident had a fall, while RSA (certified nurse aide) was transferring resident to w/c (wheelchair) using sit to stand machine. RSA (certified nurse aide) stated that she noted resident was sliding from sling and she lowered resident to the floor safely. Resident sustained skin tear to left face and left elbow. Area clean and dry dressing applied by nurse on duty. No distress or discomfort noted at the time. ROM (range of motion) at resident's baseline. V/S (vital signs) WNL (within normal limits). -On 6/6/23 a nurse documented: Resident was reported to have fallen from the sit to stand mechanical device when she was being transferred to her WC (wheelchair). RSA (certified nurse aide) stated that she noticed her sliding from the sling, and reached, and lowered her to the floor. Initial assessment was done by (name), RN (registered nurse). Res. (resident) was found sitting on the ground with her back resting on the bed frame. She appears not to be in any distress, but talking away. Not able to follow command per baseline. Noted open area to left side of cheek, and left elbow with scant blood and intact skin. She was removed from the floor with multiple attendants, and put back on her WC (wheelchair). On 6/9/23 Weekly Body Check note revealed skin tear on left cheek from a fall. 3. Facility Response a. The facility amended the resident's comprehensive care plan to read, I have had an actual fall with no injury in the last quarter on 6/6/23, fall witnessed, no injury. Interventions included: Educate and remind me about safety reminders and what to do if a fall occurs. Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. I need to be evaluated for, and supplied with appropriate adaptive equipment or devices as needed. Re-evaluate for continued appropriateness and to ensure least restrictive device or restraint. Transfer: I require total dependence (2) (two) staff to move between surfaces. Lifted mechanically. (Date Initiated 5/17/2023. Revision on 6/14/2023). Transfer: I require transferring extensive x1 (one staff) when my tone is good, and I am able to participate in the transfer. I am not able to participate in the transfer, I need to be a transfer of x2 (two staff) with a Hoyer (total lift). (Date Initiated 5/17/2023. Revision on 6/23/2023) b. Facility investigation and staff training The NHA provided the facility misuse of equipment occurrence investigation of the resident's 6/6/23 fall on 7/27/23 at 6:00 p.m. It read in part: Resident was being transferred per her usual routine when her knees buckled resulting in the care partner lowering her to the floor. The nurse assessed the resident for injury noting 2 (two) small skin tears but otherwise resident OK. Nurse spoke with care partner for support and offered education on transfers. -Immediate action included, Evaluated all transfers of residents using mechanical lift to determine still appropriate. Immediate education provided for sit-to-stand lift. -Conclusion: Resident (#2) no longer appropriate for this transfer (sit-to-stand lift). The facility provided staff education dated 6/15/23 on sit-to-stand lift transfers. 4. Facility failure The facility failed to ensure staff understood the proper method to transfer Resident #2 safely and interviews indicated staff continued to transfer the resident using a sit-to-stand lift, contrary to the conclusion of the facility investigation (see above). See the care plan revision above; the Transfer directives (Revisions 6/14 and 6/23/23) were inconsistent with the conclusion in the facility's investigation of Resident #2's 6/6/23 fall. LPN #1 was interviewed on 7/27/23 at 3:06 p.m. She said Resident #2 was able to participate in the sit-to-stand lift on her good days and if she knew the staff. She said the CNA who transferred the resident on 6/6/23 when the fall occurred did not work frequently in the facility. CNA #5 was interviewed on 7/27/23 at 3:11 p.m. She said she worked with Resident #2 frequently and the resident was comfortable with her with stand pivot transfers or while using the sit-to-stand lift. CNA # 4 was interviewed on 7/27/23 at 3:12 p.m. He said the resident was able to follow his verbal cues with transfers. He said he knew the resident very well and could recognize when the resident was safe to use a sit-to-stand lift on her good day or needed a total lift. The NHA was interviewed on 7/27/23 at 6:00 p.m. She said the CNA who transferred the resident received the facility transfers training in April 2023. The training included stand pivot transfers, slide board transfers, transfers with weight-bearing restrictions, and sit-to-stand transfers. She said the CNA was no longer working in the facility. 47351 III. Resident #20 A. Resident status Resident #20, age 88, was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, chronic kidney disease, polyneuropathy (malfunction of small vessels throughout the body), hypotension (low blood pressure), and complete atrioventricular block (electrical signals cannot pass to the chambers of the heart to allow proper blood flow). The 6/15/23 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was 13 out of 15 indicating the resident was cognitively intact. The resident required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and physical help, in part, with bathing/showering. The resident was unsteady on his feet and was not able to stabilize with staff assistance. The resident was occasionally incontinent of both bowel and bladder. The resident used a walker for ambulatory support and/or a wheelchair. B. Observations 7/24/23 -At 11:40 a.m. the resident was seated in a wheelchair sitting in the dining room with an older adult female.The resident stood up from his wheelchair and attempted to back away from the table. A CNA assisted the resident to sit down. -At 4:10 p.m. the resident was sitting in the dining room at the same table. A CNA sits and speaks with the resident about his need for assistance with his meal and reminded the resident to not get up from the table 7/25/23 -At 12:43 p.m. the resident was seated in a recliner in the activities room with his feet elevated and a neck pillow atop his shoulders. The resident was squirming in his seat, trying to sit up, moaning, and moving his hands back and forth under his thighs. 7/26/23 -At 10:19 a.m. to 10:43 a.m. the resident was seated in the activities room in a wheelchair among 4 other residents; he asked a staff member to put his feet down because he felt trapped. -At 12:40 pm the resident was moved from the dining room to the activities room and transferred from wheelchair to recliner by a male staff member. The resident declined to have his feet elevated saying he felt trapped. 7/31/23 -At 11:05 a.m. the resident was sitting in the dining room drinking a cup of coffee, looking into the cup, and attempted to rise from the chair. A male CNA comes toward the resident and eases the resident down to the chair. The CNA sits with the resident for 2 minutes. C. Record review The fall prevention care plan, initiated on 3/17/23, read Resident #16 was at a high risk for falling due to activities of daily living self care performance deficit, bowel/bladder incontinence, acute/chronic pain, and limited physical mobility. The fall interventions read, physical therapy evaluate and treat as ordered or as needed, review information on past falls and attempt to determine cause of falls. Alter or remove any potential causes if possible, and educate the resident, the family, and caregivers/interdisciplinary team as to the cause. The fall prevention plan of care was not revised until 3/30/23 after three separate fall events occurred. The resident was evaluated and treated with physical therapy beginning 6/8/23 (one day after three separate falls) for gait training therapy. Therapeutic approaches focused on remediation targeted at joint pain and stiffness, flexibility, adaptability, and efficiency of performance. Fall on 3/18/23 The 3/18/23 at 12:43 a.m. nursing investigative fall report read a CNA heard a voice and entered the resident's room and found the resident on the floor face down partly under the bed with both under garment and gown removed both of which were at the end of the bed. The resident said he needed the bathroom and took a step or two and could not walk. The resident was rolled onto a draw sheet and assisted to a wheelchair. Vital signs were stable and neurological checks were at baseline. A skin assessment revealed the resident sustained an abrasion to the left knee and a bruise to the left side of his forehead. The resident said he may have hit his head. The on-call provider was notified and advised the nurse to monitor the resident closely and to send the resident to the emergency room if there were changes to the resident's vital signs. The resident's oxygen saturation was at 80% and the nurse placed the resident on 5 liters of oxygen via a non-rebreather mask that increased the residents' oxygen saturation to 100% over 10 minutes. Predisposing physiological (normal function) factors included bowel/bladder urgency/frequency, gait imbalance, impaired memory, weakness, and confusion. Responsible parties are notified, spouse was not called. -The facility failed to reinforce

Based on observations, record review and interviews, the facility failed to ensure housekeeping services provided and maintained a sanitary resident enviornment. Specifically, the facility failed to ensure housekeeping staff: -Properly performed hand hygiene during cleaning and disinfecting a resident room/bathroom; -Properly cleaned and disinfected a resident's room/bathroom; and, -Adhered to the appropriate wet/contact/dwell time (the time a chemical must remain in contact on a surface in order to eradicate organisms) for disinfection. Findings include: I. Professional standard Centers for Disease Control and Preventions: Healthcare-Associated Infections (HAIs) 4.1 General Environmental Cleaning Techniques was reviewed on 4/21/2020 and was retrieved on 8/18/22 at https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. The document revealed, to clean from a clean area to a dirty area to avoid spreading dirt and microorganisms. Clean low touch surfaces before high touch areas surfaces. Proceed form high areas to lower areas (top to bottom) to prevent dirt and microorganisms from dripping/falling onto surfaces below thus contaminating already cleaned surfaces. Further, clean environmental surfaces before cleaning floors. Some common high touch surfaces were sink handles, bedside tables, call bells, door knobs, light switches, bed rails, wheel chairs, and counters where medications or supplies were prepared. MedlinePlus Cleaning, Disinfecting and Sanitized dated 9/23/2020 was retrieved on 8/18/22 from https://medlineplus.gov/cleaningdisinfectingandsanitizing.html. The article revealed cleaning was the removal of dirt, dust, crumbs, and germs from surfaces or objects. Cleaning would likely involve the use of soap (or detergent) and water to physically clean off the surfaces and objects. This procedure might not necessarily kill the germs. However, the removal of some germs might reduce the spread of infection. Disinfecting was the use of chemicals (disinfectants) to eliminate (kill) germs on surfaces and objects. Disinfectants are left on the surfaces or objects for a specified period (dwell) of time to kill the germs. Disinfecting does not necessarily clean dirty surfaces or remove all of the germs. If a surface or object were cleaned and disinfected; this could further reduce the risk of spreading an infection. There are products that clean and disinfect at the same time. Dwell Times Explained dated 4/7/21 was retrieved on 8/18/22 from https://vitaloxide.com/blogs/blog/dwell-times-explained. The Environmental Protection Agency (EPA) defined dwell time as the amount of time that a sanitizer or disinfectant must be in contact with a surface and remain wet to achieve the product's advertised elimination (kill) rate. Disinfect solutions could target a wide range of pathogens, and the surfaces these pathogens inhabit could vary greatly. To ensure a surface has been thoroughly disinfected, it was essential to always pay attention to the dwell time recommendations on the product's label. Some pathogens, such as Norovirus (which causes severe gastrointestinal symptoms), were particularly tough to eliminate and are highly contagious. It is essential to understand that cleaning and disinfecting are not the same. Unfortunately, these two procedures were commonly (incorrectly) used synonymously. In essence, cleaning is not disinfecting and disinfecting is not cleaning. II. Facility policy and procedures The COVID-19 Guidelines, effective 7/26/22, was provided by the regional director of clinical services (RDCS) on 8/16/22. The guidelines revealed for environmental cleaning, the staff were to ensure frequent daily cleaning with an environmental protection agency (EPA)-registered, hospital-grade disinfectant of commonly touched environmental surfaces to decrease environmental contamination. The Infection Control and Prevention policy, approved in August 2021, was provided by the RDCS on 8/16/22. The purpose of the policy was to provide care and services to seniors. It was important to prevent the transmission of communicable diseases and infections; and minimize the potential for infections in residents, associates, volunteers, contractors and visitors. Residents and associates of the facility would follow comprehensive infection control standards based on preventing, identifying, reporting, investigating, and controlling infections and communicable diseases; and complying with regulation, including mandatory reporting guidelines. Standard precautions, including hand hygiene were taught and monitored. For the skilled neighborhoods, there was a designated Infection Preventionist and the Facility Assessment will be used to assess effectiveness. The Cleaning Scope: Start to Finish procedures (undated) was provided by the environmental services coordinator (ESC) on 8/17/22 at 2:01 p.m. The document revealed to spray QT5 (commercial disinfectant) on all sinks, counter tops, door knobs, light switches, toilets and showers/tubs and leave the disinfect on for the specified dwell time. Use the Crème cleanser and scrub the sink and faucet, any tough spots on the counter tops (rinse thoroughly as it can leave a grainy film). Use a tile brush to get in crevices around the drains and the rubber attached at the bottom of the disposal drain. Use paper towels to dry out the sink when finished. Wipe down all available countertops (move counter top items and wipe underneath). Spot clean the cupboards both top and bottom. Clean the inside and outside of the microwave. Wipe down the top and front of the stove. Wipe the handles of the ice/water dispenser and the front of the refrigerator. Wipe the door knobs and the light switches. Also, use the Crème cleanser to and retrieve the toilet bowl brush and scrub the toilet. Wipe down the back of the commode, top, seat, base (in that order) and do not forget the hardware. Return the toilet brush to the housekeeping cart and dispose of gloves and wash hands (dry out the sink). Put on new gloves and obtain a clean rag. The Chemical list purpose and dwell time document, (undated) was provided by the environmental services coordinator (ESC) on 8/17/22 at 2:01 p.m. It revealed the QT5 was a one-step cleaner and disinfectant with a dwell time of one minute for Coronavirus and five minutes time for Norovirus. III. Observations On 8/17/22 at 9:25 a.m., a housekeeper (HSK) #1 was observed cleaning and disinfecting resident room #4131. This was a private room with a private bathroom. HSK #1 put on a new pair of gloves before she entered the room. HSK #1 cleaned and disinfected the room in the following sequence: -9:26 a.m., she sprayed the room sink with OT5 (disinfectant). -9:27 a.m., she wiped the entire sink with a sponge. -9:27 a.m., she turned on the water to rinse out the sink. -9:28 a.m., she obtained a new rag and dipped the rag into a solution of water and QA5 that was in a red bucket. She used the rag to wipe the entire inside of the room sink. She used the same rag to wipe off the counter top, paper towel dispenser and the hand soap dispenser. -9:29 a.m., she obtained a dry rag to wipe the entire inside of the sink, sink handles, counter top and the front of the cabinet doors. -9:31 a.m., she poured Crème cleaner into the toilet bowl. She next sprayed QT5 inside the toilet and then outside of the entire toilet (rim, seat, lid, handles, tank and pedestal). She then poured light acid bowel cleaner into the toilet bowl. All of the five chemical containers, a red bucket and a blue toilet brush holder were positioned on the bathroom floor. -9:32 a.m., she obtained a toilet brush from a blue brush holder and brushed the inside of the toilet bowl. -9:32 a.m., she obtained a sponge that was in a compartment of the blue toilet brush holder to wipe the toilet rim. She used the same sponge to wipe the seat, lid, tank, handles and then the pedestal. -9:33 a.m., she obtained a dry rag to wipe down the toilet rim, seat, lid, tank, handles and then the pedestal. -9:33 a.m., she used the same dry rag to wipe the three grab bars that were located on the walls by the toilet. -9:34 a.m., she sprayed the entire shower with the QT5. -9:35 a.m., she sprayed the bathroom mirror with a window cleaner and wiped it down with paper towels. -9:36 a.m., she sprayed a supreme heavy duty cleaner on the bathroom sink. She obtained a new sponge and wiped down the sink. She ran the water into the sink. She used a dry rag to wipe the sink and countertop. -9:37 a.m., she sprayed QT5 on the bathroom counter top and wiped it with the same dry rag. -9:38 a.m., she used the same dry rag to wipe the towel bar and the cabinet front doors. -9:38 a.m., she obtained QT5 from the red bucket and another sponge to wipe the entire shower stall down. She scrubbed the walls and the floor with the sponge. -9:39 a.m., she sprayed the shower chair with QT5. She used the shower head to spray the entire shower down with water. -9:40 a.m., she used the same dry rag to wipe down the shower chair. -9:41 a.m., she placed the five containers of chemicals, the red bucket and the blue toilet brush holder from off the bathroom floor and placed them on the room sink counter top that had previously been cleaned. -9:42 a.m., she used a broom to sweep the front entrance tile floor. -9:43 a.m., she used a broom to sweep the tile floor of the bathroom floor. -9:44 a.m., she replaced a roll of toilet paper in the bathroom holder. -9:45 a.m., she bagged up two trash cans. -9:48 a.m., she obtained a mop strip from a yellow bucket located on the housekeeping cart that was located in the hallway. The yellow bucket contained a solution to clean floors. She placed the strip on a mop handle and left it on the floor in the entrance way. She touched the room door handles as she went in and out of the room. She also touched her keys to open a door on the housekeeping cart. -9:49 a.m., she sprayed stainless steel cleaner and polish on a new rag to wipe off the dresser, television stand, wood table, bed over table, small lamp table, headboard and a wood chest located by the entrance door. -9:54 a.m., she got a new rag and sprayed the same chemical on the rag. She wiped the lamps, picture frames, window ledge, television and several pictures hanging on the walls. -9:56 a.m., she used a dust sweeper from the housekeeping cart and dusted off the wall picture frames and the ceiling lights. -9:58 a.m., she mopped the entrance tile floors. -9:59 a.m., she mopped the bathroom with the same mop strip. -10:00 a.m., she removed all of the items from the room sink countertop and placed them on the housekeeping cart in the hallway. She took the one set of gloves off and then used hand sanitizer. IV. Staff interviews HHSK #1 was interviewed on 8/17/22 at 10:00 a.m. She said she had been in-serviced on how to clean and disinfect a resident's room. She was unsure of the dates. She said the red bucket contained a mixture of water and QT5 that was premixed in the janitor's closet. She said the yellow bucket on the housekeeper cart contained premixed water and floor cleaner. The environmental services coordinator (ESC) was interviewed on 8/17/22 at 11:17 a.m. She said HSK #1 had been in-serviced on how to clean and disinfect a resident's room about a year ago. She said since that time HSK #1 had not received any additional training on how to perform this task. The methodology of how HSK#1 had cleaned/disinfected the resident's room, was discussed with the ESC. She said HSK #1 should have changed her gloves three or four times during the entire process. She said it was unacceptable for HSK #1 to have used the same pair of gloves for the entire process. She said the room should have been cleaned top to bottom and HSK #1 should have followed the specific dwell times for the products that she used. She said spraying a chemical on a surface and immediately wiping off the surface with a rag was not acceptable. She said HSK #1 should have followed the facility procedures for cleaning/disinfecting a resident's room. She said HSK #1 should not have used a rag to wipe from dirty to clean surfaces. She said HSK #1 should not have used a dry rag to wipe from the toilet rim, outward to the remainder of the toilet and the tank. She said the HSK #1 should not have placed the four chemicals bottles, toilet brush holder and red bucket from off the bathroom floor onto the previously cleaned sink counter top that was in the resident's room. She said HSK #1 should have washed her hands after she was done cleaning the room. She said HSK #1's methodology for cleaning this resident room was incorrect. She said HSK #1 had been working in the facility for the past ten years and should have known how to clean and disinfect a resident's room correctly. On 8/17/22 at 2:03 p.m., the ESC said she was unable to find the in-services on how to clean and disinfect a resident's room for HSK #1. She said the Cleaning Scope document needed to be updated to include additional (two or more) glove changes during the process. She said HSK #1 should have changed her gloves at least after cleaning the bathroom. The environmental services employee (ESE) was interviewed on 8/17/22 at 2:05 p.m. He said HSK #1 had been in-serviced on cleaning and disinfecting a resident's room about two years ago and the last time was less than a year ago. He was unable to provide the documentation of the in-services. He said HSK #1 should have changed her gloves at least twice during the process. He said HSK #1 should have cleaned the room from top to bottom and from clean to dirty. The nursing home administrator (NHA) was interviewed on 8/17/22 at 4:15 p.m. She said the reason to clean and disinfect a resident's room correctly was to prevent the risk of infections and to provide for the wellbeing of the resident.

Based on record review and interviews, the facility failed to ensure residents had the right to a dignified existence. Specifically, the facility failed to ensure residents experienced a dignified living experience by answering the call lights timely for two (Resident #9 and Resident #13) of 16 out 20 residents and addressed continued call light complaints voiced during resident council for several months. Findings include: I. Facility policy A call light policy was requested during survey 5/23/22 to 5/25/22; however the executive director (ED) reported the facility did not utilize a call light policy. The Resident Rights policy, dated August 2021 was received by ED on 5/25/22 at 8:10 a.m. It documented, in pertinent part, All residents have the right to equal access to quality care regardless of diagnosis, severity of condition, or payment source. The community will encourage and assist residents in the fullest possible exercise of these rights. Residents have the right to the reasonable accommodation of residents' needs as long as it does not endanger the health or safety of residents or other residents. Residents have the right to voice grievances on behalf of themselves or others to the associate of the Community, government officials or any other person and to join with other residents and individuals within or outside of the Community to work for improvements in resident services and care. The Community must promptly resolve issues presented. II. Resident interviews All residents were identified by facility and assessment as interviewable. Resident #9 was interviewed on 5/23/22 at 9:23 a.m. He said there had been times it took up to an hour for staff to answer his call lights. Resident #13 was interviewed on 5/23/22 at 10:25 a.m. She said staff took over an hour to answer her call light and it recently happened one evening when she wanted to get in bed. III. Record review 1. Call light log The call light log was received by the ED on 5/25/22 at 8:10 a.m. It documented the following from 5/11/22 to 5/24/22: Resident #9 -On 5/13/22, 5/17/22, 5/19/22 and 5/20/22 the resident waited 20 to 26 minutes for his call light to be answered. -On 5/11/22 and 5/12/22 the resident waited 30 to 33 minutes for his call light to be answered. -On 5/13/22, 5/16/22 and 5/22/22 the resident waited one hour for his call light to be answered. Resident #13 -On 5/11/22, 5/12/22, 5/14/22, 5/18/22 and 5/23/22 the resident waited 20 to 28 minutes for her call light to be answered. -On 5/11/22, 5/16/22, 5/21/22 and 5/22/22 the resident waited 30 to 34 minutes for her call light to be answered. -On 5/19/22 the resident waited one hour for her call light to be answered. 2. Resident council minutes Review of the 3/9/22 resident council minutes revealed a resident reported it was still taking staff a long time to respond to his/her call light. The assistant director of nursing (ADON) stated she would run a call light audit and educate the staff. Review of the 4/13/22 resident council minutes revealed residents stated it took too long for a care partner to answer their call light. The ADON's response was to trial an increase in staff at bedtime/evening to help with the call light response. Review of the 5/11/22 resident council minutes revealed residents continued to report long call light wait times. The resident council group was informed that the facility was in the process of having non-nursing associates carry a device to receive call light notifications so that there were more staff answering call lights. IV. Observation and staff interviews Certified nurse aide (CNA) #3 and the ADON were interviewed 5/24/22 at 3:34 p.m. The ADON said they switched to using mostly phones instead of pagers in December 2021, and felt the facility showed some improvement with their Wi-Fi call light system. CNA #3 demonstrated how the call light system worked as the facility had three different mechanisms in which the resident could call for assistance, nurse call (the wall call cord), pendant (call button which was placed around the resident as a necklace) and the bathroom call cord. CNA #3 activated the nurse call cord/button then the pendant call cord/button in room [ROOM NUMBER]. As the light was activated the light could be viewed on the main monitor at the nurse's station and on staff pagers and cell phones. The ADON said if you cleared the wall system, at times staff could not hear the alert on their phone. She acknowledged that the pendant call was viewable on the phone even though the alert was not sounding, so at any point the staff could still see that there was an alert initiated in that room and if they had been in to assist the resident at that time they should have cleared the call light. V. Additional interviews The ADON was interviewed a second time on 5/25/22 at 12:28 p.m. She said the staff competencies did not include orientation to Wi-Fi call light system and it was not included on the new staff checklist. She said staff were educated during their two to five day shadowing orientation but it was not anything they needed to sign off on for completion. She said the facility was aware of the call light concerns from residents and she planned to re-implement rounding; but just had not gotten to it because of all the duties she had been taking care of as interim director of nursing, minimum data set (MDS) coordinator, infection preventionist (IP) and covering for the social services director at times. The executive director (ED) was interviewed on 5/25/22 at 2:57 p.m. He said he and the ADON had implemented an actual call light audit form to complete rounds, but the ADON was the only who was rounding and now he realized issues started rising up again. He acknowledged problems with answering call lights as it was a continuous problem voiced in resident council and planned to re-implement rounding with their audit form.

Based on resident record review and staff interviews, the facility failed to collaborate with the hospice provider to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (#6) of two out of 20 sample residents. Specifically the facility failed to: -Ensure adequate and timely documentation and coordination of care with the hospice agency; and, -Ensure there was written documentation of hospice visits for approximately four months, which included hospice staff not speaking with the facility nursing staff about their visits. There was no documentation the resident received from hospice the care planned twice weekly showers. Findings include: I. Facility policy The Hospice/Palliative Care Coordination policy, dated August 2021, was provided by the nursing home administrator (NHA) via email on 5/25/22 at 8:10 a.m. It revealed in pertinent part; The written agreement shall include, at a minimum, the following: How the Community and hospice and/or palliative care will communicate with each other and coordinate services. The Director of Nursing (DON) / Health and Wellness Director (HWD) or a designee is responsible for coordinating care that is ordered by the practitioner/healthcare provider and documenting this in the resident's service plan/care plan. The hospice and/or palliative care provider (shall) sign and shall adhere to standards set forth in the agreement. Which include but not limited to the following: Provide documentation for the resident record as soon as practicable. Provide a verbal or written report to the DON .or designee on a regular basis (weekly is preferred) or more frequently if indicated (e.g. change in resident condition/status) or per Community expectations set forth during service coordination. II. Resident #6 A. Resident status Resident #6, age over [AGE] years, was admitted on [DATE]. According to the May 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/6/22 quarterly minimum data set (MDS) assessment revealed the resident had severe cognitive impairment and was unable to answer questions during a brief interview for mental status (BIMS). She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The resident was on hospice care and services. III. Record review The long term care plan 5/27/21 documented the resident signed on with hospice services. Pertinent interventions with hospice providers included, responsibility for the coordinated plan of care, assessed effectiveness of pain medication, collaboration with patient and family/caregiver regarding medications, treatments, and care needs. The hospice staff was to provide routine bathing/showering twice per week for the resident and facility staff was to provide showers per as needed. The hospice provider had a log book on the nurse's station. The log book was reviewed during survey on 5/23/22. The sheets for documented visits were titled the Facility Integration Tool. The sheets were to document hospice service provider's visits which included: days the resident was visited by the hospice nurse, hospice aide, social worker, chaplain, music therapist, or other staff who visited the resident. The tool had sections to document showers, incontinence care, and shampooing of the resident's hair. Hospice was to utilize the documentation tool to document each time the resident received visits and services provided. -The log book had the following documented visits from the hospice provider: -On 12/20/21 a music therapist visited. -On1/3/22 the resident was provided a shower by the hospice certified nurse aide (CNA). -On 1/17/22 a music therapist visited. -On 1/28/22 a CNA washed the resident's hair. There was no documentation of a received shower. The last visit entry in the hospice provider's log book was handwritten on 1/28/22. Approximately four months had passed with no written documentation. (See below nurses interviews) The last facility electronic medical records (EMR) entry for hospice care was on 7/12/21. (See medical record director interview below) The care plan 7/27/21 and revised on 3/10/22 revealed the resident might have less than six months to live due to [CONDITION(S)]. Resident #6 was to be provided routine showers twice per week by the hospice provider and the facility was to provide showers per as needed. The hospice CNA was to come visit the resident and provide care twice per week, and hospice nursing care was to provide visits one time per week. The resident was to work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs were met. The facility shower log was reviewed on 5/24/22 and a 30 day look back period did not reveal any showers were provided to the resident from the facility staff. The resident's medical chart on the nurse's station contained information in a plastic sleeve. The plastic sleeve had a prior hospice company's name, and phone numbers to call should the facility staff need to contact hospice. -The medical chart did not contain information about the current hospice provider. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 5/23/22 at 10:23 a.m. He said he was unaware the hospice provider had not documented any visits in the resident's hospice log book since January 2022. He said That particular hospice provider does not generally communicate with the facility nursing staff when they are in the building. I can ' t remember the last time I saw them in the building. He said maybe the medical records director (MRD) had documentation in their office. He said the hospice providers were to write in their communication books that were on the nurse's station every time they visited the residents. The medical records director (MRD) was interviewed on 5/23/22 at 10:30 a.m. She said she was unaware the last EMR hospice record was from July 2021. She said she was unaware there were no current hospice provider notes in the EMR. The assistant director of nursing (ADON) was interviewed on 5/24/22 at 12:43 p.m. She said she was the prior director of nursing (DON) but now was the ADON. She said she was the acting DON until the position was filled. She said she was unaware the last logbook documentation from the hospice provider was January 2022. She said the facility did not know when that hospice provider was in the building because they did not get reports from them. She said the hospice company did not collaborate with the facility staff. She said there was no documentation the resident had received a shower over the last four to five months. She said the facility did not know if Resident #6 was visited by a nurse, a CNA or had received showers from her hospice provider. She said the facility staff did not document showers in the resident EMR because it would mean that the facility staff had given the shower. She said she did not know when Resident #6 had her last shower. She said the facility had a problem with the hospice provider and she said it seemed they changed staff often when she would call them to complain. She said she called the hospice provider yesterday during the survey to tell them to send over any visit notes they had, if any. Licensed practical nurse (LPN) #1 was interviewed on 5/24/22 at 2:35 p.m. He said a new documentation was added to the hospice log book yesterday. He said the hospice CNA documented she spoke to a qualified medication administration person (QMAP) and had the QMAP sign off that a visit had been provided. LPN #1 said in a skilled nursing facility there were only nurses and there were no QMAPs who provide care. He said he did not know who the hospice provider would have spoken to as there were no signatures of facility staff on the log sheet either. He said he did not know when hospice providers for this resident were in the building because they did not provide reports to the nursing staff. The hospice clinical director (HCD) was interviewed over the phone on 5/24/22 at 3:25 p.m. She said the facility staff had called the hospice company during survey about the lack of documentation on Resident #6. She said she did not know why there were no notes to document care since January 2022. She said her staff were to write and date every visit in the hospice binder at the nurse's station. She said if one of her staff had to miss a visit that should have been documented also. She said We take part ownership in this situation. I don't know if we have ever been invited to a care conference at the facility. I did not know the previous contact provider's information was in the resident's chart at the nurse's station. We should have a sticker on the resident's chart with our hospice provider's phone numbers for who to call. -However, there was no sticker on the resident's chart with the current hospice provider. She said a CNA visited the facility yesterday and she said she was unaware the CNA wrote a QMAP signed off that she was in the building when there were no QMAPs in the facility, only nurses. The social service director (SSD) was interviewed on 5/25/22 at 9:40 a.m. She said she invited Resident #6's hospice provider to attend the resident's care conferences on 9/13/21 and 1/3/22. She said the hospice provider did not respond to her invite and they did not attend. She said the resident's family lived in England and it would be helpful to have the hospice provider be a part of care conferences. She said she was unaware the wrong hospice company with their contact information was in the resident's chart on the nurse's station. She said she did not know who was responsible to ensure the correct hospice information was in the chart. She said I can tell you we have tried to terminate their contract before and get a different hospice company for the resident. I cannot say without documentation if the resident had a shower in the past several months. V. Facility follow-up The MRD was interviewed again on 5/24/22 at 10:10 a.m. She said the ADON called the hospice provider during the survey to send the facility any visit notes of visits they had done. She said what she did receive, she electronically uploaded into the records during the survey as well as added printed copies into the hospice binder. The ADON was interviewed again on 5/25/22 at 11:00 a.m. She said that hopefully the hospice company would collaborate with the facility in the future. She said she would ensure the correct information was in the resident's chart to call the correct hospice company. She said she would make sure the resident had showers and that it was documented. She said on 5/24/22 during the survey she and the MDR added in the resident's EMR and in the hospice book on the nurses station any notes from the hospice provider that they currently received. The nursing home administrator (NHA) on 5/26/22 at 11:03 a.m. emailed further information. The NHA wrote the information (provided) was not kept at the nurse station but was in the resident's closet. The email included some hospice visit documentation not signed off by facility staff and the hospice Integration Tool policy. It revealed in pertinent part: The Hospice agency will coordinate services with each long-term care/assisted living provider. The hospice and provider will jointly ensure collaborative, integrated efforts between the long-term care provider and the hospice, by documenting which services will be provided, by whom, the frequency of services, updates when changes occur, dated signatures of both long-term care provider and hospice staff. The Facility Integration Plan of Care will be initiated by the Hospice provider upon start of care in the LTC (long term care) and will be continuously updated with any changes as needed and at recertification. Procedure Complete the Hospice resident name, corresponding room number, and Hospice diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Complete the name of the Hospice agency, phone numbers and staff assigned for each discipline. Circle the days of the week the hospice nurse plans to visit. Update any ongoing schedule changes on the next line. Circle the days of the week the hospice aide plans to visit. Update any ongoing schedule changes on the next line. List the frequency of visits planned for the social worker, chaplain, music therapist or other staff. Update this section by marking through the previous schedule with one line and listing the new schedule with the current date. Indicate at the bottom of the page, signatures and dates of review for both facility representative and the Hospice staff member making the changes. The document is not considered completed without both Hospice staff and Facility staff signatures.

Based on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 12%, or three errors out of 25 opportunities for error; registered nurse (RN) #1 failed to ensure Resident #4 had an order to crush medications prior to administration; and RN #1 crushed a medication for blood pressure ([MEDICATION(S)]) which should not have been crushed. Findings include: I. Facility policy The Medication Administration policy dated 2007, was received by the executive director (ED) on 5/25/22 at 8:10 a.m. It documented, in pertinent part, Prior to administration, review and confirm MEDICATION ORDERS FOR [MEDICAL RECORD OR PHYSICIAN ORDER] . The need for crushing medications is indicated on the resident's orders and the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Long-acting, extended release or [MEDICATION(S)]-coated dosage forms should generally not be crushed; an alternative should be sought. For products that appear on the Medications Not To Be Crushed List, check with the pharmacist regarding a suitable alternative, and request a new order from the prescriber if appropriate. II. Observation of medication errors and staff interview RN #1 was observed preparing Resident #4's medication on 5/24/22 at 9:27 a.m. RN #1 prepared [MEDICATION(S)] (anticoagulant) 2.5 mg (milligram) tablet, [MEDICATION(S)] (extended release blood pressure medication) 100 mg one and half tablets, and Tylenol (pain reliever) 500 mg two tablets. RN #1 said Resident #4 accepted her medications crushed, then placed Resident #4's medications in a plastic sleeve and crushed them, placed them in apple sauce and administered them to the resident. III. Staff interviews RN #1 was interviewed on 5/24/22 at 3:58 p.m. He said staff should obtain an order to crush medications from the physician prior to medication administration. He confirmed Resident #4 did not have an order to crush medications. He said he thought it was okay to crush [MEDICATION(S)], but needed to contact the pharmacist to ensure it could be crushed. RN #1 was interviewed a second time on 5/24/22 at 4:07 p.m. He said he contacted the pharmacist and the physician who stated [MEDICATION(S)] should not be crushed. He said the physician implemented new orders to discontinue [MEDICATION(S)] and start [MEDICATION(S)] [MEDICATION(S)] 100 mg twice daily and he received a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The assistant director of nursing (ADON) was interviewed on 5/24/22 at 4:52 p.m. She said staff should obtain orders to crush appropriate medications from the physician prior to administration. She said the facility had standing orders to crush appropriate medications; however, the order still needed to be verified by the physician. The regional clinical specialist (RCS) was interviewed on 5/25/22 at 1:52 p.m. She said the facility started an action plan. She said the physician changed Resident #4's blood pressure medication to a crushable form. She said she completed a full house audit of residents who received their medications crushed to ensure the resident's had a crush order from the physician. She said the facility discovered three other residents who did not have an order to crush medications. She said moving forward the facility had an audit in place to ensure those residents who needed their medications crushed had an appropriate order, started education with nursing staff and planned to complete medication management competency with all nursing staff.

Based on interviews and record review, the facility failed to ensure two (#1 and #2) of three out of three sample residents were kept free from abuse. The facility failures to ensure a system was in place prevent neglect to Resident #1. Resident #1 who was a known high fall risk, was not provided care and services needed according to her fall risk care plan. Resident #1 was care planned to have bed in the lowest position. The failure of staff to ensure the bed was in the lowest positioned contributed to neglect of Resident #1 who fell and sustained a left hip joint fracture and required hospitalization . -Additionally, the facility failed to ensure Resident #2 received the necessary supervision and assistance while in the bathroom. The resident fell when left unattended in the bathroom and sustained multiple skin tears. Findings include: I. Professional references According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html (Retrieved 9/14/2020), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Neglect is the failure to meet an older adult ' s basic needs. These needs include food, water, shelter, clothing, hygiene, and essential medical care. II. Facility policy and procedure The Resident Abuse Non-Tolerance policy and procedure, reviewed March 2020, was provided by the nursing home administrator (NHA) on 9/10/2020 at 11:38 a.m. It revealed, in pertinent part, Residents and clients must be free from abuse by anyone, including associates, other residents, consultants or volunteers, associates from outside agencies, family members or legal guardians, friends or other individuals. Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Examples of neglect include but are not limited to: failing to provide needed care such as not responding to a call light, failing to nourish, toilet, hydrate a resident, etc. The Fall Prevention and Management policy and procedure, revised August 2018, was provided by the NHA on 9/10/2020 at 11:38 a.m. It revealed, in pertinent part, The purpose of the fall prevention and management program is to identify residents/clients and areas at risk for falls, initiate interventions to prevent and respond to falls and thus reduce the risk of injury due to falls. A fall is a sudden, unintentional descent, with or without injury to the person, that results in the person coming to rest on the floor, on or against some other surface. III. Failure to ensure care and services were provided to prevent a severe injury following a fall for Resident #1 A. Resident #1 1. Resident status Resident #1, age 100, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The 8/24/2020 minimum data set (MDS) assessment revealed the resident had short term and long term memory impairment and had severe impairment in making decisions regarding tasks of daily life. She required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident was under hospice care. It indicated the resident sustained [REDACTED]. 2. Record review The impaired cognition care plan, initiated 11/17/17, revealed the resident had impaired cognitive function and dementia and impaired thought processes. It indicated the resident required supervision and assistance with all decision making. The fall risk care plan, initiated on 11/17/17 and revised on 7/21/2020, revealed the resident was classified as a high risk for falls. The interventions included a safe environment with floors free from spills or clutter, adequate glare-free light, a working and reachable call light, the bed in the low position at night, handrails on the walls and personal items within reach. It indicated the intervention of a low bed had been in place since 11/17/17. The actual fall care plan, revised on 8/25/2020, revealed the resident sustained [REDACTED]. The intervention included to ensure the resident ' s bed was in the low position when she was lying down. It indicated care providers should be educated in the residents' need for the bed to be in the low position. The 8/24/2020 incident progress note revealed the resident was taken to the hospital following a fall. It revealed the resident appeared to be in pain at the time of the transport to the hospital and the bed was found in the highest position. The 8/26/2020 (noted late entry for 8/24/2020) nursing progress note revealed a certified nurse aide (CNA) entered the nursing station searching for help. The CNA and registered nurse (RN) entered the resident ' s room on 8/24/2020 at approximately 4:00 p.m. and found the resident lying on the floor. The resident was lying on her left side with her back against the wall, facing the rear of the bed. The 8/27/2020 (noted late entry for 8/24/2020) nursing progress note revealed the resident was found on the floor, lying on her left side. It indicated the resident had fallen out of the bed, which was observed to be in the highest position. The nurse said the resident was last attended to by the hospice agency CNA and could have left the bed in an unsafe position. The resident was observed to be groaning and guarding the left thigh. The paramedics arrived at the facility and transported the resident to the hospital. The 8/25/2020 social services progress note revealed the resident ' s family had contacted the facility to inform the resident had been transferred from the hospital to an in-patient hospice facility. The resident ' s family contacted the facility again on 8/28/2020 to notify the resident had passed away that morning. The 8/24/2020 hospital physician encounter notes revealed the resident was admitted to the hospital following a fall and sustained a displaced [MEDICAL CONDITION] acetabulum (socket of the hip bone) extending superior laterally. It indicated after discussion with the resident ' s family, the goals of the resident were comfort care and did not want any aggressive measures. The risk and harm of surgical management outweighed the benefits of surgical intervention. The physician transferred the resident to an in-patient hospice facility for aggressive palliative and symptomatic care. 3. Staff interviews The hospice case manager was interviewed on 8/31/2020 at 5:04 p.m. She said she was an active part of the resident ' s hospice care, which was provided at the facility. She said she visited the resident weekly. She said she was aware the resident ' s plan of care indicated the resident ' s bed should be in the low position due to the resident ' s fall risk status. She said on 8/24/2020, two hospice CNAs entered the facility to provide a bed bath to the resident at 1:34 p.m. She said the CNAs clocked out of the facility at 2:05 p.m. She said she interviewed both CNAs that provided care to Resident #1 on 8/24/2020. She said both CNAs were interviewed separately and provided the same recollection of events. She said CNA #2 and CNA #3 provided a bed bath to the resident. She said following the bed bath, CNA #2 said they placed the resident underneath the covers and put the resident ' s bed in the lowest position. CNA #2 said CNA #3 went into the resident ' s bathroom to wash her hands. While CNA #3 was washing her hands, CNA #2 said she sat down at the foot of the resident ' s bed. CNA #3 said after she was finished washing her hands, they informed the nurse they had completed the bed bath and left the facility. CNA #2 said if the bed had been in the highest position, then she would not have been able to sit on the end of the bed due to her height. The HCM said she did not believe CNA #2 and CNA #3 left the bed in the highest position. She said each CNA was interviewed separately and gave the same account of events during the day. CNA #1 was interviewed on 9/10/2020 at 10:54 p.m. He said he had worked at the facility for many years. He said he regularly provided care to Resident #1. He said Resident #1 was considered a high fall risk due to her cognitive impairment. He said when the resident was in the bed, the bed should be placed in the low position. He said the resident was able to roll side to side on her own. He said the staff would always place the call light within reach before leaving the resident alone in the room, when she was in bed, even though the resident was unable to use the call light. He said she would not know how to use the bed controls to move the bed up and down. He said Resident #1 would not have been able to use the bed controls to move the bed to the highest position on her own without assistance. He said it was communicated to him, the facility did not know who left the bed in the highest position on 8/24/2020, when the resident fell out of bed. He said the staff assumed it was the hospice CNAs but was not certain. He said the resident was very kind and did not deserve to fall out of her bed in that manner. The NHA and the director of nursing (DON) were interviewed on 9/1/2020 at 12:26 p.m. The NHA said the facility conducted an investigation following the fall Resident #1 sustained on 8/24/2020. The DON said the resident was found on the floor on 8/24/2020 at approximately 4:00 p.m. She said the resident complained of pain on the left side and was transferred to the hospital. She said while the resident was at the hospital, it was determined she had sustained a fracture to the hip joint. She said it was her understanding, hospice CNAs had provided care to the resident and left the facility around 2:00 p.m. She said the resident was not found until 4:00 p.m. by the facility staff. The NHA said the facility was unable to determine what staff member left the resident ' s bed in the highest position. He said the facility staff said they did not leave it in the highest position and so did the hospice staff. He said the facility substantiated the neglect because the resident was not provided the care and services consistent with her plan of care which led to her fall and fracture. He said, because of conflicting interviews, the facility was unable to determine who left the bed in the highest position. The DON was interviewed on 9/10/2020 at 11:45 a.m. She said neglect occurred when a resident was not provided the care and services they required to avoid physical harm. B. Resident #2 1. Resident status Resident #2, age 98, admitted on [DATE]. According to the September 2020 computerized physician's orders [REDACTED]. The 7/16/2020 minimum data set (MDS) assessment revealed Resident #2 had short term and long term memory impairment. Resident #2 utilized a wheelchair and had an unsteady gait. Resident #2 required total dependence on staff regarding activities of daily living including toileting. 2. Record review The care plan initiated 2/20/18 and last revised 2/3/2020 identified Resident #2 needed extensive assistance with most activities of daily living (ADLs). The Interventions used by staff documented Resident #2 needed extensive assistance with toileting and transfers. The care plan further revealed staff were to provide privacy but to remain in line of sight. Review of the nurse progress note dated 7/22/2020 documented Resident #2 had an unwitnessed fall when Resident #2 was sat on the toilet and left unattended. When Resident #2 fell , she sustained skin tears to forehead, right knee, right elbow and shearing on the buttocks. 3. Staff interview Licensed practical nurse (LPN #1) was interviewed on 9/10/2020 at 10:58 a.m. he said on the evening of 7/22/2020 Resident #2 had been seated on the toilet and fell . (Resident #2 had been left unattended and required assistance to be within reach). LPN #1 said Resident #2 had a sitter that worked with her in the evenings due to being a fall risk. LPN #1 stated the sitter was not known to make mistakes like this and should have asked for help. He stated Resident #2 had sustained multiple small skin tears. The director of nursing (DON) was interviewed on 9/10/2020 at 11:38 a.m. regarding the fall. She said it was a poor decision on the sitter's part. DON said the sitter should not have been assisting Resident #2 to the restroom. DON said the sitter was not a CNA and she should have gotten assistance from the facility staff. The DON confirmed that she, the sitter, had been educated before working with the Resident #2 and she received further education after the fall so this mistake would not occur again in the future. She said Resident #2 received multiple skin tears and was healing. The DON said new ways of training were being implemented with additional oversight being put in place to ensure resident safety.

Based on observation, record review and interviews, the facility failed to consistently follow accepted infection control practices to prevent the potential spread of Coronavirus 2019 (COVID-19). Specifically, the facility failed to follow Center for Disease Control and Prevention (CDC) guidelines to prescreen screen all employees for possible symptoms of COVID-19 prior to the start of their shift. Findings include: I. Standard According to the CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last revised 4/12/2020, Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. Retrieved online from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. II. Facility policies and procedures The Clinical Coronavirus 2019-n-CoV Guidelines, dated February 2020, provided by the nursing home administrator (NHA) on 5/5/2020 at 9:44 a.m., read in pertinent part: Prompt detection effective triage and isolation of potentially infectious persons are essential to prevent unnecessary exposures among residents/clients/guests, associates, healthcare personnel and visitors at the community. The Non-clinical Coronavirus 2019-n-CoV Guidelines, dated February 2020, provided by the NHA on 5/5/2020 at 9:44 a.m., read in pertinent part: Monitor and manage exposed associates: -Movement and monitoring decisions for healthcare professionals with exposure to 2019-nCoV should be made in consultation with public health authorities. The Community Screening for COVID-19 procedure, dated 4/20/2020 provided by the NHA on 5/5/2020 at 11:55 a.m., read in pertinent part: Screening will be performed on visitors and associates and will be logged. Records must be maintained and available for surveyors, as requested. Ensure privacy in documentation. Screening of questions below and for temperature will be done on associates and visitors attempting to enter Community. For Colorado only, each screening must also be documented on a separate form. III. Failure A. Record review Staff screening sheets were provided by the NHA on 5/5/2020 at 9:50 a.m. Review of staff screening sheets for clinical care staff working all shifts 5/1/2020 through 5/5/2020 revealed the facility failed to maintain documentation that the clinical staff were consistently screened each time they entered to work a shift. The facility was unable to produce screening documentation for the following staff: -Licensed practical nurse (LPN) #1 working 5/2/2020 at 5:00 a.m. -LPN #1 working 5/3/2020 at 5:00 a.m. -Certified nursing aide (CNA) #1 working 5/3/2020 at 6:00 p.m. -CNA #2 working 5/5/2020 at 6:00 p.m. B. Interviews The concierge was interviewed on 5/5/2020 at 8:10 a.m. She said each staff coming into work was to complete the COVID-19 Screening Questionnaire for review. After reviewing the questionnaire she took their (staff) temperatures for the record. Staff were permitted to enter for work unless they had any concerning symptoms and/or a temperature of 100.0 Fahrenheit or higher. The staff development coordinator (SDC) was interviewed on 5/5/2020 at 9:30 a.m. The SDC said staff were not permitted to begin work until they were screened for possible symptoms of coronavirus. A trained staff is stationed at the concierge desk from 6:00 a.m. to 7:00 p.m. to screen employees as they enter for their shift. When there was no concierge assigned to the front desk, staff were to report to the concierge's desk at the assisted living entrance. The assisted living front was staffed 24 hours a day seven dates a week. Once screened and cleared to start work staff had to walk back around the building to get remote access to the skilled nursing facility entrance so they were not walking through areas they were not assigned to work. The NHA, director of nursing and SDC were interviewed on 5/8/2020 at 9:00 a.m. The NHA said the facility had four concierge staff who were trained and competency tested to screen and temperature test employees for potential symptoms of coronavirus prior to their start of work. The NHA said the concierge staff made sure each staff completed the COVID-19 screening questionnaire, reviewed their answers and were to report any concerning symptoms immediately to management. The NHA said because staff were occasionally screened at the assisted living desk, their screening sheets were sometimes misplaced. She said, We will look for the missing COVID-19 Screening Questionnaire sheets and forward them for review. C. Follow-Up The NHA forwarded a secured email on 5/5/2020 at 5:09 p.m. The email contained additional staff COVID-19 Screening Questionnaire forms that had been requested at the end of the day of the onsite survey visit. The facility was able to locate and forward 14 of the 18 requested staff screening sheets.

Based on observation, record review and staff interviews, the facility failed to ensure essential laundry dryer equipment was in safe working order in the facility laundry room. Specifically, the facility failed to: -Ensure the vent system for two dryers was properly connected to prevent lint build up in and around the open flame ignitor, and -Keep the dryer lint filters cleaned per manufacturer's instructions. Findings include: I. Professional reference According to Unimac technical literature (2013) Operation and Maintenance manual for Model UT055N, retrieved from: http://unimac.com/Service-and-Support/technical-literature/search-results.aspx?model=UT055 Risk of fire, a clothes dryer produces combustible lint. Exhaust outdoors. Care should be taken to prevent the accumulation of lint around the exhaust opening and in the surrounding area. In addition, the manufacturer's manual for operation documented that at the end of the day, the lint filter should be cleaned to maintain proper airflow and avoid overheating. II. Dryer vent system [NAME] Observations On 10/31/19 at 2:00 p.m. the laundry room was reviewed with housekeeper (HK) #1. Two dryers were observed, labeled Unimac, model number UT055N. The mechanical room behind the dryers was observed. The walls, ignitor box, pipes and equipment were covered in a layer of lint.The vent pipe from the dryers to the outside was observed to have come apart and was not sealed. There was an ignitor box to the left inside the room with open flames shooting upward. HK #1 said she did not go into that room and did not have any information about the room. On 10/31/19 at 3:50 p.m. the mechanical room behind the dryers was observed with the nursing home administrator (NHA) and building operations director (BOD). The vent pipe was separated and the room had a layer of lint on the walls, ignitor box, pipes and equipment. B. Interviews The NHA was interviewed on 10/31/19 at 3:55 p.m The NHA observed the room and ignitor box covered in lint, and said the separated vent pipe was a fire hazard. The BOD was interviewed on 10/31/19 at approximately 4:00 p.m. He said the vent had come apart and that was why there was lint all over the room. He said it was a fire hazard. The BOD said he inspected the room monthly, but had no log of the inspections. He said he did not have a copy of the manufacturer's instructions but printed some information from an online site. The BOD was interviewed again on 10/31/19 at 4:43 p.m. He said he placed screws in the vent to secure it and had retaped the connections. He said he had cleaned the open flame ignitor box area of lint. C. Facility follow-up On 10/31/19 at 4:43 p.m. the dryer mechanical room was observed again with the BOD. The dryer vent tubing had been resecured with screws, and the lint on the open flame ignitor box had been cleaned. The room continued to have lint on the walls, pipes and equipment. The BOD said he would finish cleaning the room that evening. On 11/1/19 at 8:57 a.m. the BOD provided a log titled Laundry Room Dryer Inspection Log. The first entry on the log was dated 10/31/19, and documented dryer vent pipe came apart and not sealed, lint all over the room. Repaired vent pipe, sealed seam with tape, cleaned the walls and back of dryers to remove lint from room. On 11/1/19 at 9:10 a.m. the mechanical room for the dryers was observed with the BOD. The walls, open flame ignitor box, pipes and equipment had been cleaned of lint. III. Dryer lint filters [NAME] Observations and interview The lint filters for the two dryers were observed on 10/31/19 and 2:00 p.m. with HK #1and noted to be full, with additional lint on the bottom of the box holding the filter. HK #1 said the filters were cleaned twice daily. The lint filters were observed again on 10/31/19 at 4:43 p.m. with the NH[NAME] She said the laundry staff had gone home for the day. The lint filters remained full. The NHA said the filters were not being cleaned or they wouldn't be like that. The facility failed to clean the lint filter at the end of each day per manufacturer's instructions. On 11/1/19 at 8:52 a.m. the lint filters in the dryers were observed with the maintenance director. The lint filters were still completely full of lint. The maintenance director said one of his laundry persons cleaned the lint filters in the morning, but he did not know when the other person was cleaning them. B. Record review A document hanging in the laundry room, titled Monthly Cleaning Log (MONTH) 2019, was reviewed. The log had a check mark one time daily next to the words dryer lint. There was no documentation to indicate the lint was cleaned twice daily as HK #1 reported she had done. In addition, there were no check marks on the log from 10/21/19 through 10/25/19 to indicate the filters were even cleaned once daily.

Based on observations and interviews, the facility failed to consistently provide sanitary meal services in one of one food service location. Specifically, the facility failed to: -Follow accepted hand hygiene and glove use practices; -Replace heavily scored cutting boards; and -Avoid potential cross contamination of food and food contact surfaces. Findings include: I. Hand hygiene and glove use [NAME] Professional standards According to Colorado Retail Food Establishment Rules and Regulations (CRFERR), effective 1/1/19, pages 47-48: Food employees shall clean their hands and exposed portions of their arms . (E) After handling soiled equipment or utensils; (F) After handling soiled equipment or utensils . (H) Before donning gloves to initiate a task that involves working with food; (I) After engaging in other activities that contaminate the hands. According to the CRFERR, effective 1/1/19, page 74, Gloves, Use Limitation. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. B. Observations An initial observation of the food service area was completed on 10/29/19 at 11:45 a.m. Follow up observations were completed on 10/31/19 at 12:05 p.m. and 11/1/19 at 8:15 a.m. and 12:15 p.m. There were numerous observations of staff failing to wash their hands prior to donning and after doffing single use gloves. During meals on 10/31/19 and 11/1/19, the prep cook moved from task to task while wearing single use gloves. The gloves she used were kept in a drawer under the service table. Each time she retrieved a pair of gloves, she used her hands to open the drawer and touched the clean outer surface of the gloves as she placed them on her hands. She used the gloves to touch potentially contaminated surfaces such as the refrigerator handle, meal tickets and other kitchen equipment that others had handled before cleaning their hands. The prep cook used the gloves to touch ready to eat food including bread, the crust of a quiche and fruit as it was sliced. The food services worker was observed on 11/1/19 at 8:17 a.m. with a cutting glove in her pocket. She placed the cutting glove over her gloved hand and placed another clean glove over the top of the fabric glove. She did not wash her hands prior to touching the outer surface of the clean glove. The food services worker used the glove to hold several sausage patties in place as she chopped them. Neither staff cleaned their hands when donning and doffing gloves until prompted by the regional clinical nutrition manager to do so. The prep cook was interviewed on 10/31/19 at 12:15 p.m. She said she worked in a number of food service settings and was assigned to the main kitchen before coming over to the nursing home. She said the facility was short on staff at the time and did not have time to provide her with dietary training. She said she had training on food handling at previous jobs but nothing since coming to the facility. II. Cutting Boards [NAME] Professional Standards According to the CRFERR, effective 1/1/19, page132, Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. B. Observations Cutting boards were observed with heavily scored and stained surfaces during the initial tour of the kitchen on 10/29/19 at 10:40 a.m. A black cutting board was used to chop food items next to the steam table in the nursing home food service area. The surface was heavily scored and was used multiple times during each meal. III. Cross contamination [NAME] Professional standards According to the CRFERR, effective 1/1/19, page 77: During preparation .food shall be protected from environmental sources of contamination. B. Observations On 10/31/19 at 12:15 p.m., the prep cook retrieved a stack of plates from the warmer. She carried the plates against her body as her apron rested against the food contact surface of several plates. A toaster was located next to the designated hand sink in the nursing home food service area. On 11/1/19 at 8:15 a.m. the prep cook was making toast. Two open bags of bread were placed between the toaster and the hand sink as the bread was toasted. Staff entering the food service area washed their hands in the proximity of the open bags, increasing the likelihood for contamination of the food items. On 11/1/19 at 8:25 a.m., the prep cook plated a slice of quiche for a room tray order. She placed the resident's meal ticket directly on top of the quiche as she finished preparing the tray. The prep cook and the food service worker were observed on multiple occasions using their hands to touch the food contact surfaces of plates and dessert bowls. Prior to touching these clean surfaces, the staff had touched meal tickets, the refrigerator handle, other kitchen equipment and/or had adjusted their clothing. On 11/1/19 at 12:12 p.m., the prep cook used the corded telephone next to the steam table to call the kitchen. The phone cord draped across a partially covered container of food that was placed next to the cutting board and steam table. On 11/1/19 at 12:35 p.m., meal tickets were placed on the cutting board surface. The tickets were later removed so the board could be used to chop a food item. IV. Staff interviews The observations were shared with the dietitian and director of dining services (DDS) on 11/1/19 at approximately 3:25 p.m. The dietitian and the DDS said staff were expected to follow clean and sanitary practices during the meal service. The DDS said the potential for contaminating food was increased when staff did not follow accepted practices for safe food handling. The dietitian said staff would be re-educated and monitored closely to ensure compliance with expectations.

Based on observations and staff interviews, the facility failed to ensure food was stored and served at safe temperatures in order to prevent the potential for food-borne illnesses. Specifically, the facility failed to ensure cold food was stored below 41 degrees Fahrenheit (F) in the walk-in and small refrigerator in the dining and service area. Findings include: A. Professional Reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (last amended (MONTH) 21, 2012, effective (MONTH) 1, 2013) page 39, The temperature of potentially hazardous food shall be 41 degrees F (5 degrees (Celsius (C)) or below or 135 degrees F (57 degrees C) or above at all times, except during necessary periods of preparation or as otherwise provided in code. B. Failures of the walk-in cooler 1.Walk-in cooler observations and interviews An observation of the kitchen was completed on 10/1/18 at 8:15 a.m.revealed the temperature of the walk-in cooler was measured at 45 degrees F, according to the appliance thermometer inside the cooler. A second observation of the kitchen was completed on 10/2/18 at 8:38 a.m. The temperature of the walk-in cooler was measured at 44 degrees F, according to the appliance thermometer. one calibrated thermometer was placed inside the cooler and, after acclimation, measured temperatures of 45 degrees F. 2. Interviews On 10/2/18 at 8:46 a.m., the cook observed the temperatures in the walk in cooler. The thermometer recorded temperatures of 45 degrees F. The cook said the temperature should be below 40 degrees F. At 8:46 a.m. The registered dietician (RD) observed the temperature inside the walk-in cooler. One thermometer was placed on the second shelf. The RD observed the temperature and . The RD stated the temperature was measured at 44.1 degrees F. The DM said the temperature should have measured 40 degrees F or below. She said she would get maintenance to check the temperatures immediately. C. Failures of the small refrigerator 1.Small refrigerator observations and interview On 10/1/18 at 11:41 a.m. the refrigerator in the dining service area was measured at 45 degrees F. 2. Interview At 11:41 a.m. the RD observed the refrigerator in the dining room service area. The RD stated the temperature was difficult to read but appeared to be about 45 degrees F. She said she would get maintenance to check the temperatures immediately. D. Additional interview The director of dining services (DDR) was interviewed on 10/4/18 at 3:51 p.m. She said she was notified of the higher temperatures of the walk in cooler and the refrigerator in the dining serving area. she said the temperatures should measure between 34 and 40 degrees F. She said all of the product was removed and disposed of to ensure the safety of residents. The DDR said maintenance was notified immediately and lowered the thermometers and logged temperatures. She said the potential risk to the residents was increased risk of bacterial growth, food borne illness, increased spoilage of food which could cause the residents to become ill.

Based on observations, record review, and interviews, the facility failed to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year for five out of five certified nurse aides (CNA) reviewed. Specifically, the facility failed to have an in-service education program that measured not only by documentation of hours of completed in-service education, but also by demonstrated competencies of nurse aide staff through written exam and/or in consistently applying the interventions necessary to meet residents ' needs as identified in the facility assessment to include safe transfers with a mechanical lift (cross-reference F689). Findings include: I. The facility assessment The facility assessment revised 3/20/18 was provided upon entrance and included the following information: -Staff training, education and competencies: training topics included activities of daily living. The staff offered individualized care for residents to include transfers using a gait belt, and mechanical lifts for residents. -The facility conducted a monthly safety meeting which reviewed resident and staff injuries and reviewed facility safety policies and procedures. -Areas the facility assessment was informed included training and competencies. The action to be taken or already taken this year included for training and competencies read: Maintain compliance of employee completion of training modules and schedule competency evaluation for staff. Nursing competencies completed in early part on (YEAR). II. Record review Review of six CNA files and interview with one hospice CNA revealed the following: -CNA #1 was hired in (MONTH) (YEAR) and there was no evidence of training or competency for safe transfers and mechanical lifts. -CNA #2 there was no evidence the CNA completed 12 hours of training beyond dementia and abuse training to include training or competency for safe transfers and mechanical lifts. -CNA #3 there was no evidence the CNA completed 12 hours of training beyond dementia and abuse training to include training or competency for safe transfers and mechanical lifts. -CNA #4 there was no evidence the CNA completed 12 hours of training beyond dementia and abuse training to include training or competency for safe transfers and mechanical lifts. -CNA #5 there was no evidence the CNA completed 12 hours of training beyond dementia and abuse training to include training or competency for safe transfers and mechanical lifts. -CNA #6 there was no evidence the CNA completed 12 hours of training beyond dementia and abuse training to include training or competency for safe transfers and mechanical lifts. -Hospice CNA (HCNA) there was no evidence the HCNA completed training or competency for safe transfers and mechanical lifts. The facility did not provide evidence of current training for CNAs #2, #3, #4, #5 and #6. The skills training provided varied from 2011 to 2014. The skills training and competencies provided for CNA#1 did not include safe transfers and mechanical lifts. III. Staff interviews The HCNA was interviewed on 10/2/18 at 10:33 a.m. She said she did not have formal training on how to use the sit to stand mechanical device from facility staff. She said some of the CNAs showed her how to use it. CNA #1was interviewed on 10/2/18 at 1:29 p.m. She said she had training on basic resident care and transfers by her mentor, CNA #6 within the last couple of months. She said she was hired in (MONTH) of (YEAR). CNA #5 was interviewed on 10/2/18 at 1:29 p.m. She said training was provided when she was hired three and a half years ago. She said a mentor and another CNA provided the basic resident care and training. The licensed practical nurse (LPN) #1 was interviewed on 10/2/18 at 2:32 p.m. He said the CNA mentors attended special training to become mentors which included completing competencies for new CNAs. He said new CNAs shadowed a mentor for a minimum of three days a completed check off lists daily to ensure the training was completed. He said the mentors decided, whether the new CNAs were ready to provide care alone. He said he thought competencies were completed yearly. The LPN said the hospice CNAs were certified to use mechanical lifts because they completed CNA classes and that was part of the education. The director of nursing (DON) was interviewed on 10/2/18 at 2:42 p.m. She said the therapy department provided training for the staff on the use of mechanical devices. She said the information provided was all she had available to her. She did not know where the training records were. The director of rehab services (DRS) was interviewed on 10/2/18 at 3:45 p.m. She said she had not provided training to anystaff for safe transfers and mechanical lifts. The DON was interviewed on 10/4/18 at 2:12 p.m. She said the competencies and skills checklist completed by the mentors was supposed to go to her when completed to review. She said she could not recall if she had reviewed skills and competency checklists since she was hired. She said she had to check with human resources for the information. The DON said she had not reviewed CNA #1s skills and competencies signed off by the mentor. She said it was a system issue the facility needed to work on.

Based on observations, record review and interviews, the facility failed to ensure the environment remained as free of accident hazards as possible and failed to provide adequate supervision and assistance devices to prevent accidents for four (#22, #6, #14 and #129) of seven residents reviewed for accidents out of 16 sample residents. Specifically, the facility failed to: -Investigate, develop and implement, monitor and modify interventions to prevent Residents #22, and #6 from repeat falls. -Keep Resident #129s environment free from straws as ordered to reduce the risk of aspiration. -Failed to ensure Resident #14 was transferred in a safe manner. Cross-reference F947 failure to ensure staff were properly trained. Findings include: I. Resident #22 A. Resident #22 status Resident #22, over the age of 85 was admitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 9/13/18 minimum data set (MDS) assessment revealed the resident displayed short and long-term memory problems and her decision making ability was moderately impaired. She was rarely to never understood by others. She required extensive assistance of one person with bed mobility, transfers, dressing and toilet use. She had not had any falls since the previous assessment. B. Record review 1. Care plan The comprehensive care plan, revised 9/18/18, revealed she had an ADL (activities of daily living) self-care performance deficit. She required extensive assistance of one person with toileting. She was at high risk for falls and had an actual fall on 9/18/18. The fall interventions included: -Provide extensive assistance of one person with toileting. Do not leave me alone on the toilet.(8/31/18) -Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. (8/31/18) -PT (physical therapy) to treat as ordered or PRN (as needed). (8/31/18) -Review information on past falls and attempt to determine the cause. Record possible root causes. Alter and remove any potential causes if possible. Educate me, my family, my caregivers and IDT (interdisciplinary team) as to causes. (8/31/18) -Check range of motion with daily cares. (9/18/18) -For no apparent acute injury, determine and address causative factors of the fall at the time of the fall and during follow-up fall rounds. (9/18/18) -Monitor, document and report to MD for signs or symptoms of: pain, bruises, change in mental status, confusion, sleepiness, inability to maintain posture and agitation. (9/18/18) -Provide 1:1 (one on one) activities if bedbound. (9/18/18) -PT consult for strength and mobility. (9/18/18) 2. Certified nurse aide (CNA) Kardex care card The CNA Kardex revealed the following care instructions: -Safety: Distract me from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. I prefer: Visiting in the nurses station. -Safety: Monitor, document and report PRN any risk for harm to self: suicidal plan, past attempt at suicide, risky actions, intentionally harmed or tried to harm self, sense of hopelessness or helplessness, impaired judgment or safety awareness. -Transfers: I require extensive assistance of one staff to provide assist to move between surfaces. -Toileting: I require extensive assistance of one person to provide assist with toileting. Do not leave me alone on the toilet until I have been evaluated. -Resident care: I have a companion at night from home care. 3. Review of falls, interventions and DON interviews a. Fall #1 The 9/1/18 nurses ' note read, in pertinent part, CNA called this nurse and notified resident was on floor. Res (resident) was restless and tried to get up from w/c (wheelchair) multiple times the res brought by nurses station for close monitoring. Res was asleep on (sic) recliner with tab alarm on when CNA went to answer other res. light. When CNA back she found res on the floor. This nurse noted res sat up on the floor by the w/c. Tab alarm removed and found on the recliner. Res unable to explain what happened. The fall was reviewed with the DON on 10/4/18. She stated the intervention was for staff to put the resident in the recliner by the nurses ' station for increased supervision. She stated, She needed to have a sitter but the husband did not want her to have a sitter. She was unable to show the care plan had been revised post fall. b. Fall #2 The 9/9/18 nurses ' note read, in pertinent part, Resident observed on the floor. RN (registered nurse) called and head to toe assessment completed, large wound to elbow about 8 cm (centimeters) long and 3 cm wide, moderate bleeding and pressure applied. Another deep cut noted on right forehand about 3 cm long and 1.5 cm wide. Call placed to provider on call and new orders given to send resident to the ER (emergency room ) to receive stitches on the right forehand deep cut. Resident husband aware of situation. The 9/10/18 daily skilled note read, in pertinent part, Resident does not have sitter any more and was sitting at nurses ' station to prevent her from falling. The 9/10/18 care conference note read, in pertinent part, He (husband) had discontinued 24 hour services from (home care agency) and Resident #22 fell after that. The fall was reviewed with the DON on 10/4/18. She stated the husband was in the room at the time of the fall so the new intervention was to provide education to the staff that they must check on the resident even when the husband is in the room. She was not able to provide evidence the education was completed and she was unable to show the care plan had been revised post fall. c. Fall #3 The 10/3/18 nurses ' note read, in pertinent part, This writer was notified by companion caring for res stating that res was on the floor. Res was found on the floor sitting butt naked. Prior to res being found on the floor, res was noted sitting on her couch with her husband. Companion stated that the whole episode happened so fast, she stated that as she was trying to pull res brief up, after res was done using the bathroom res sat down really fast and before she could react, res sat down, missed her w/c and landed on her butt. The fall was reviewed with the DON on 10/4/18. She stated the companion was not a CNA and should not have assisted the resident to the toilet. She said she had spoken to the agency and had requested all companions who were used by the facility be re-educated regarding their scope of practice. She said the facility staff would also be re-educated to make sure they are checking on the resident when the husband or the companions are with her. C. Staff interviews CNA #3 was interviewed on 10/4/18 at 10:12 a.m. She said the resident has a sitter with her 24 hour now due to her falls. She said the sitters would sometimes take the resident to the bathroom but we help when they need help. She stated she did not know the sitters could not assist the resident to the bathroom. She said the nurses would update them with new fall interventions. Licensed practical nurse (LPN) #2 was interviewed on 10/4/18 at 10:30 a.m. She said the resident required the one-on-one sitter because she was very restless and impulsive. She said the nurse would assess the resident for injuries post fall and evaluate the area to try to determine what caused the fall. She said the nursing staff would initiate fall interventions whenever they were able to determine the cause. She said these interventions would be communicated through daily report. She said the MDS coordinator was responsible for updating the care plan with new interventions. II. Resident #6 A. Resident #6 status Resident #6, over the age of 90, was admitted [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 7/22/18 MDS assessment revealed the resident ' s cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required extensive assistance of one person with bed mobility, transfers, locomotion on and off of the unit, dressing, toilet use and personal hygiene. He required limited assistance of one person with ambulation. He was unsteady and required staff assistance to stabilize with moving from a seated to a standing position, walking, turning around and moving on and off the toilet. B. Record review 1. Care plan The comprehensive care plan, revised 9/18/18, revealed the resident had an ADL self-care performance deficit and required extensive assistance of one person with transfers and toileting however, his ambulation needs were not identified. He was at high risk for falls and had an actual falls on (MONTH) 2, (YEAR). The fall interventions included: -Educate and remind me about safety reminders and what to do if a fall occurs. (6/6/18) -Encourage me to participate in activities that promote exercise, physical activity for strengthening and improved mobility. (6/6/18) -I have a tab alarm on me at all times for my safety. (8/9/18) -I need to be evaluated for, and supplied with appropriate adaptive equipment or devices as needed. Re-evaluate for continued appropriateness and ensure least restrictive device or restraint. (6/6/18) -I need a safe environment; i.e. even floors free from spills and/or clutter, adequate glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls; personal items within reach. (6/6/18) -PT to evaluate and treat as ordered or PRN. (6/6/18) -Review information on past falls and attempt to determine the cause. Record possible root causes. Alter and remove any potential causes if possible. Educate me, my family, my caregivers and IDT as to causes. (6/6/18) -Check range of motion with daily cares. (7/2/18) -For no apparent acute injury, determine and address causative factors of the fall at the time of fall and during follow-up fall rounds. (7/2/18) -Monitor, document and report to MD signs or symptoms of pain, bruises, change in mental status, confusion, sleepiness, inability to maintain posture and agitation. (7/2/18) -Provide 1:1 (one on one) activities if bedbound. (7/2/18) 2. CNA Kardex care card The CNA Kardex revealed the following care instructions: -I require extensive assistance of one person with transfers and toileting. -I have a tab alarm on me at all times for my safety. 3. Review of falls, interventions and DON interviews a. Fall #1 The 6/25/18 nurses ' note revealed the resident had a witnessed fall in the dining room. He fell while attempting to pick up his napkin from the floor. The wheelchair rolled back and he sat on the floor. He did not lock his w/c upon reaching to pick the napkin from the floor. The fall was reviewed with the DON on 10/4/18. She stated the staff were educated to assist him with locking the wheelchair brakes. She was unable to provide evidence of this education nor was this intervention found on the care plan or CNA kardex. b. Fall #2 The 6/28/18 incident note read, in pertinent part, Resident was found on floor in bathroom. Res stated he went to use the bathroom after having been placed by CNA on lounge sofa after therapy. No call light within reach. Res w/c in room, FWW (front wheeled walker) not used to get to bathroom. Res had a large goose egg to the back left of head and ? (complained of) generalized pain. The resident was sent to the hospital for an evaluation. The resident returned from the hospital with a [DIAGNOSES REDACTED]. The fall was reviewed with the DON on 10/4/18. She stated she thought this fall occurred in the common area bathroom. She said the intervention included making sure to shut the bathroom door when not in use and to make sure staff are there (in the common area) all of the time. She was unable to show the care plan was revised post fall. c. Fall #3 The 7/2/18 daily skilled note read, in pertinent part, Resident #6 has been repeatedly hollering out for help whether or not he has his call light on. If it is on it may only be for seconds and he is hollering. He has been up pacing in his room without assistance. He had an unwitnessed, non-injury fall this evening as a result. He cont ' s (continues) to walk in his room (without his walker) despite falling. Tab alarm was and is in place but this does not deter him. The fall was reviewed with the DON on 10/4/18. She was unable to find an incident investigation for fall and thus could not speak to interventions identified or implemented. d. Fall #4 The 7/28/18 incident note read, in pertinent part, F/U (follow up) from a fall on 7/27/18. No nursing progress note found related to fall. The DON provided an incident report on 10/4/18, which read, Resident was found sitting on the floor in his room by the side of the chair he was sitting before. Resident was assessed all all ROM (range of motion) were active. Resident was trying to go to the bathroom himself without help. The fall was reviewed with the DON on 10/4/18. She stated the staff are supposed to make a progress note whenever there is a fall. She said the intervention for this fall was to provide him with increased supervision. The DON stated she did not assess the resident for a bladder program even though this was the second fall in the bathroom. e. Fall #5 The 8/20/18 nurses ' note revealed the resident was found on the floor in the activities bathroom. The resident stated, I was washing my hands at the sink and when I went to sit on my w/c I tripped on the w/c footrest and I fell on my back. The fall was reviewed with the DON on 10/4/18. She stated she had plans to rearrange things in the activity room to provide increased supervision in that area. She said staff are to make sure the bathroom door stays closed. No new interventions were implemented after the fall. f. Fall #6 The 8/21/18 nurses ' note revealed the resident had a witnessed fall in his room. The resident was getting up from his recliner and he tripped over his foot rests and he fell backwards landing on his buttocks. The fall was reviewed with the DON on 10/4/18. She stated the wheelchair footrests were removed from the wheelchair. This intervention was not identified on the care plan. g. Fall #7 The 9/2/18 post fall note revealed the resident was found sitting on the floor in his room next to the refrigerator with walker nearby. His pants were falling down because his suspenders were not in use. He reported that he was going to get a Coke and tripped on his pants. The fall was reviewed with the DON on 10/4/18. She stated the staff need to monitor him frequently because he displays unsteadiness upon rising. She said he does well once he starts walking but he has trouble when he first stands up. She stated the staff had recognized this but had not consulted therapy and he had not been assessed for orthostatic [MEDICAL CONDITION]. h. Fall #8 The 9/5/18 nurses ' note read, Resident #6s wife had just left room approximately 2 (two) minutes prior. This nurse was standing near the sink in his kitchen area and heard a scuffling sound and a thud. Turned around immediately and noted res lying supine on the floor alongside his bed with his head directly alongside the front of his nightstand. The fall was reviewed with the DON on 10/4/18. She stated the wife was educated to notify staff when she leaves for the evening so that staff can check on him more frequently. C. Staff interviews The DON was interviewed again on 10/4/18 at 3:30 p.m. She said she had recently started having fall huddles which involved all of the staff coming together after falls to determine the root cause of the fall and develop interventions. She said the care plans have not been revised with updated interventions but should be used as a communication tool for staff. She said the care plans should provide staff with instructions on fall interventions and the resident ' s needs. IV. Resident #129 A. Resident #129 status Resident #129, over the age of 90, was admitted 9//30/18. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 9/30/18 Admission Nursing Tool assessment revealed she was alert to self only and had impaired decision making abilities. She required staff assistance with all of her ADLs. She received a regular diet with thin consistency fluids and had no swallowing problems. B. Resident observation and speech therapy (ST) interview On 10/3/18 at 9:03 a.m., the resident was not in her room however, upon inspection a sign which read, NO straws please was observed hanging on the wall beside her chair. On the table beside the chair and the sign sat a large cup of water with a large straw. There was also a small cup of water with a straw beside her bed on the bedside table. The resident was in the dining room eating breakfast at the time of the observation. At 9:17 a.m.,the speech therapist (ST) was interviewed inside the resident ' s room. She stated the resident showed significant increased aspiration with the use of a straw. She observed the cups, with the straws and immediately removed them from the room. C. Record review 1. Physician orders The (MONTH) (YEAR) CPO revealed a diet order dated 10/2/18 which read, Regular diet, mechanical soft texture. Thin consistency. No straws, assistance at meals. 2. Care plan The care plan, initiated 10/2/18, revealed the resident had the potential for nutrition and hydration risk. The interventions included to honor her food preferences and provide her diet as prescribed. The diet, revised on 10/3/18, read, Regular diet/mechanical soft texture/nectar-thick liquids. The care plan failed to identify the resident was not supposed to use straws per physician order. The CNA Kardex care card failed to identify the resident was not supposed to use straws. 3. Speech therapy note The 10/3/18 ST note read, in pertinent part, Pt. has an order for [REDACTED]. D. Staff interview The DON was interviewed on 10/4/18 at 1:30 p.m. She said the staff should not have had straws in the resident ' s room. She said this increased the residents risk for aspiration. She stated the care plan and CNA kardex should identify the resident is not to use straws. IV. The facility failed to ensure the resident was transferred in a safe manner. A. Resident status Resident #14, age 98, was admitted on [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The 8/26/18 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of zero out of 15. The resident sometimes responded adequately to simple, direct communication only. The resident usually understood others. The staff assessment of the resident's mental status revealed the resident had long and short term memory problems. The resident's cognitive skills were severely impaired and she never or rarely made decisions. She had difficulty focusing attention and her thinking was incoherent. The resident required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. B. Record review The (MONTH) (YEAR) CPO included orders for: -The use of a Hoyer (Lift) for transfers with 2(two) staff at all times. Every day and night shift for transfers the start date was 9/6/18. -The use of a sit to stand mechanical transfer device and may use Hoyer (Lift) for transfers with 2 (two) staff at all times. Every day and night shift for transfers, the start date was 10/3/18. C. Observations and interviews On 10/2/18 at 10:33 a.m. the resident was in her bathroom with the hospice CNA. The hospice CNA was waiting for a facility staff person to help her transfer the resident with the sit to stand mechanical transfer device. CNA #4 entered the room to help with the transfer. The CNAs placed the sling around the resident's arms, placed the resident's feet on the platform, tightened the strap around the resident's calf's and instructed the resident to hold on to the bars. CNA #4 placed the resident's hands on the bars. The resident removed her hands and was touching the sling. CNA #4 instructed the hospice CNA to lift the resident, she had the remote. They were informed and the transfer was stopped because the brakes were not locked on the sit to stand mechanical transfer device. CNA #4 moved the wheelchair in place and did not lock the brakes. The CNA was informed the brakes were not locked on the wheelchair, and she locked them. CNA #4 guided the resident into the wheelchair as the resident let go of the bars. CNA #4 said the resident required two staff for transfers since a lift (mechanical device) was used. He said the team (CNAs) knew the resident required two people to transfer. He said the sling had to be tight because the resident could wriggle out of it. CNA #4 said the staff also had to help guide her or she would put her hands through the sling and she could fall through it. He said she did not hold on because she did not understand. CNA #4 said the brakes on the mechanical device and wheelchair should have been locked prior to beginning the transfer to keep the resident safe. The hospice CNA said she provided care for the resident two times a week. She said the mechanical device was used for transfers and she had to call for help when she was ready to transfer the resident. The hospice CNA said she did not have formal training on how to use the sit to stand mechanical device from facility staff. She said some of the CNAs showed her how to use it. She said the brakes should have been locked to prevent the resident from getting hurt. At 1:29 p.m. CNA #1 and CNA #5 were observed transferring the resident from her wheelchair to the commode in the resident's bathroom. Both CNAs placed the sling around the resident and under her arms, they tightened it and CNA #1 asked CNA #5 which loop went onto the mechanical device. CNA #5 showed CNA #1 which one and they completed the task. CNA #5 assisted the resident with her feet on the platform and CNA #1 tightened the strap around the resident's calf's. The CNAs told the resident to hold on to the bars. CNA #1 placed the resident's hands on the bars. CNA #1 was supposed to guide the resident and CNA #5 had the remote. They were informed the brakes were not locked and the transfer was stopped. The CNAs both agreed the brakes were not locked, they forgot to do that before lifting the resident. As CNA #5 was standing the resident, the chair alarm fell to the floor. CNA #1 left the side of the resident to pick up the alarm as CNA #5 was standing the resident up. The resident was not holding on to the bars and she was crying out, Oh oh oh, I can't do this. The resident was not being guided while being stood up and moved to the commode. CNA #5 started to make the motion to lower the resident to the commode and was informed the the brakes were not locked. She stopped and locked the brakes before continuing to assist the resident with the transfer. The CNAs attached the sling to the sit to stand mechanical lift. They did not ensure the resident's feet were flat on the platform, they did not secure the resident's calf's. the resident was lifted and her legs and feet were dangling, her toes barely touching the platform. The resident was not holding on to the bars, she was touching the front of the sling on her chest. The resident was lowered into her wheelchair and she said, Oh. The CNAs took the sling off the resident and repositioned her in the wheelchair. CNA #5 said she had been provided training when she was hired three and a half years ago. She said a mentor and another CNA provided the training. She said the sit to stand lift was only supposed to be locked when the resident was sitting on the commode. She said another CNA or staff member was always next to the resident and the other CNA or staff member behind the lift. CNA #5 said she was unable to see the resident's legs during the transfer and did not know the resident's feet were not flat on the platform. She said the resident did not usually hold on because she had dementia and she said she was not sure the resident understood what to do. CNA #1 said she had been trained by her mentor, CNA #6 within the last couple of months. She said she was hired in (MONTH) of (YEAR). She said CNA #6 told her to lock the lift while lifting the resident, unlock it to move the lift and then lower the resident. She said she did not lock the lift while lowering the resident. CNA #1 said she did not lock the wheelchair because the staff needed to move the wheelchair quickly. She said the lift was not locked sometimes when the resident was being lifted because the staff had to move from one place to another. CNA #1 said the resident's feet should have been positioned and her legs should have been strapped in. She said she did not see the resident's feet were not positioned and the bottom strap was not tight and it should have been. CNA #5 said the straps were to keep the residents legs safe so the resident was not able to move her legs the way she did. She said they should have ensured the resident was holding on too. C. Record review Care plan The care plan, initiated 11/17/17 and revises 1/1/18, identified the resident had an ADL (activities of daily living) self care performance deficit because of [MEDICAL CONDITION]. Interventions included: Staff my use a sit to stand lift with (2) staff assistance for transfers. The facility did not provide evidence an assessment was completed prior to the use of a sit to stand mechanical device. The facility failed to provide evidence the facility staff and contract, specifically hospice staff, had completed training prior to using a sit to stand lift mechanical device to transfer residents. The director of rehab services provided a typed assessment she completed on 10/4/18 which read: . Due to pt's (patients) decreased cognition, at times it will be appropriate to use the hoyer lift (used for persons that require 90-100 percent assistance for transfers) if needed. D. Staff interviews LPN #1 was interviewed on 10/2/18 at 2:32 p.m. He said the therapy staff was supposed to complete an assessment and evaluate the residents to ensure the use of a mechanical device was appropriate. LPN #1 said the proper procedure to use a sit to stand lift was as follows: two people were required at all times, explain to the resident what was occurring as they performed the task, place the sling around the resident and attach it to the lift, place feet flat on the platform, ensure the legs are secured with the strap, tell the resident to hold on to the bars, one staff had to hold on to the resident and guide, make sure the wheels are locked on the lift and the wheelchair until ready to move, that was to ensure everything was sturdy as possible. LPN #1 said the CNA mentors attended special training to become mentors which included completing competencies for new CNAs. He said new CNAs shadowed a mentor for a minimum of three days a completed check off lists daily to ensure the training was completed. He said the mentors decided whether the new CNAs were ready to provide care alone. He said he thought competencies were completed yearly. The LPN said the hospice CNAs were certified to use mechanical lifts because they completed CNA classes and that was part of the education. He did not know if the facility provided additional training to the hospice CNAs to help transfer residents with a mechanical device. LPN #1 said Resident #14 was not coherent and was not able to understand directives to hold on to the bar. He said he thought a therapist had completed an evaluation, but did not know for certain. The LPN said the staff should have ensured the brakes were locked on all devices and placed hands on the resident to guide throughout the entire transfer process. He said the resident should not have been transferred when her feet were not positioned and secured. He said the resident could have obtained an injury had she fallen. The DON was interviewed at 2:42 p.m. on 10/2/18. She said transfers with mechanical devices were completed with two people. One person to stabilize the equipment and operate the equipment. The other person was supposed to actually hold the resident to make sure the resident was stable. The DON said the brakes should have been locked while preparing the resident for transfer. The DON was interviewed again at 3:23 p.m.said the facility did not have a policy or training information for the sit to stand device. She said the therapy department provided training for the staff on the use of mechanical devices. She said the director of rehab services (DRS) was going to provide training to the staff who were working in the facility and oncoming staff until all of the staff was trained. The DON was interviewed for a third time at 5:45 p.m. said she did not know if an evaluation or assessment was completed for Resident #14s use of mechanical devices for transfers. The DRS was interviewed on 10/2/18 at 3:45 p.m. She said the criteria for staff to use a mechanical device for transfers was individualized based on assessments. She said the brakes on wheelchairs, mechanical devices needed to be locked and secured, secure placement of feet, knees and hands, ensure the sling was on properly for a safe transfer. The DRS was interviewed again at 4:10 p.m.said she was unable to find notes in Resident #14 medical record regarding an evaluation or changes in condition that required the use of the sit to stand or mechanical device. The DRS was interviewed for a third time on 10/4/18 at 8:24 a.m.said she thought nursing determined the resident required a sit to stand or mechanical device for transfers. She said a request for an evaluation from therapy was not found in the resident's medical record. The DRS said the risk to the resident was an inappropriate transfer and injury of not having an assessment or trained staff. She said she was still providing training to oncoming staff on proper use of mechanical devices for transfers.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan that focused on each resident ' s goals and involved the resident or designated responsible party in the development of the plan for one (#75) of two residents reviewed for discharge planning out of 16 sample residents. Specifically, the facility failed to: -Develop and implement an effective discharge plan of care and appropriately document in the care plan and electronic record; -Assess the resident prior to discharge to reflect a safe discharge to the receiving community; and, -To involve Resident #75 in the development of her discharge plan. Findings include: A. Resident status Resident #75, age 76, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The resident did not have an admission assessment completed. B. Resident interview Resident #75 was interviewed on 10/1/18 at 1:46 p.m. She said, I ' m not supposed to stay here very long. She said she was there for rehabilitation because she broke her right arm when she fell at home. She said the plan was to go back home and her daughter was helping with the process. She said she had no idea when she was going home. Resident #75 reached for her calendar and said, It looks like this Friday and pointed to 10/4/18. She said she did not know much about the transfer home and to call her daughter for more information. C. Record Review Care plan The care plan, initiated 9/24/18 read, I wish to (SPECIFY return/be discharged ) to (SPECIFY home, another facility). The problem identified did not include specific details about discharge. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I am a high risk for falls. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. The care plan initiated 9/25/18 and revised on 9/25/18 identified the resident was receiving rehab therapy specifically, physical therapy, occupational therapy and speech therapy. Interventions were not included for the identified problem. There was one note from social services on 10/3/18. The note documented, Care conference in resident ' s suite with daughter in attendance. Staff included (name) SS (social services), (name) therapy director and name dietitian. Discussed discharge plan for last covered day to be (MONTH) 4th with discharge of Friday the 5th. Discharge orders are for 24/7 to include PT, OT, and speech. Arrangements are set for her return to (name of facility). The social services history and initial discharge plan was provided by the SSD on 10/4/15 at approximately 10:30 a.m. the information was from the original admission on 6/6/18 not the current admission on 9/23/18. The document was not updated for the current admission and discharge plan. Resident #75s electronic health record did not include information about the receiving facility, assessments and information about discharge planning for the resident. An occupational therapy treatment encounter note dated 9/28/18 was provided by the director of rehab services (DRS) on 10/4/18 at 12:21 p.m. the note read: Analysis of ALF (assisted living apartment) set-up via photos, education to resident on set-up elements that will bolster her function. Education on stabilization and body mechanics during graded cueing and supervision for ambulatory –level mobility within suite, including changing of direction, divided attention. The occupational therapy discharge note dated 10/4/18 at 11:23 a.m. included: discharge status and recommendations: -Bathing SBA (stand by assist) requires close sup (supervision) for majority of tasks for safety, may include set up but no physical contact. -ADLs (Activity of daily living) supervision, performs majority of task and set up, with therapist in room or area available for cueing as requested by patient; no physical assist required. ALF staff to provide supervision and assist as needed. D. Staff interviews The SSD was interviewed on 10/3/18 at 5:00 p.m. She said she started discharge planning for Resident #75 last month (September). She said discharge planning started at the first conference within 72 hours. She said she talked with the resident, family or both about what the plans were. She said a vast majority transitioned to assisted living or independent apartments within the community. The SSD said if the resident required nursing care at home she offered home health care to follow. She said most residents discharged with an order for [REDACTED]. The SSD said a care conference was held on 9/26/18 and then 10/3/18. She said they held a discharge meeting today (10/3/18) and provided an email (see record review above). She said the resident was not included and neither was the resident ' s daughter. She said the daughter was aware of the discharge date because she requested speech therapy in addition to occupational and physical therapy. The SSD said the assisted living facility had accepted the resident. She did not know who contacted the facility, she said she thought the daughter called them. She said she received a call from the assisted living facility and the person left a message about completing an on-site visit with the resident on 10/4/18. The SSD said all of the communication to Resident #75 through the resident ' s daughter. She said she had not communicated any information to the resident. The registered nurse manager (RNM) was interviewed on 10/4/18 at 10:28 a.m. She said a therapist completed an assessment of the resident to ensure a safe discharge. She said weekly care conference meetings were held weekly to ensure the goals were appropriate. She said the team discussed options and appropriate systems when needed. The RNM said the only concern Resident #75s daughter had was her cognition and requested speech therapy to be included at the assisted living. The RNM said the assessments began on 10/2/18 with nursing documentation. She said the rehab department staff usually went to the resident ' s home to see the living environment and make sure it was safe to go back. She did not know who contacted the assisted living facility for Resident #75 for discharge planning. She said, it was probably the resident ' s daughter. The director of rehab services (DRS) was interviewed on 10/4/18 at 12:05 p.m. the DRS said a discharge assessment had not been completed at the assisted living for Resident #75. She said she had spoken with the resident ' s daughter and had been to the assisted living facility many times and knew what it looked like. She said what the staff at the facility do and asses ensured the resident was safe to go live in assisted living. The DRS was interviewed on 10/4/18 at 12:26 p.m. the DRS said she assumed the pictures were provided by the daughter. She said that was an accurate assessment and Resident #75 was safe to go to her independent living apartment. She said staff from her department had not and did not plan on completing an on-site evaluation with the resident at her apartment before discharge. She said the occupational therapist reviewed the pictures and that was adequate. The DRS then said she did not know if an assessment was offered and declined she will look and provide information if available. The DRS said the rehab department had completed the discharge plan with the daughter during care conferences and she felt the transfer was going as planned. E. Family interview The resident ' s daughter was interviewed on 10/4/18 at 9:53 a.m. She said the facility told her on 9/26/18 her mom had 10 days of therapy. She said she was told, Monday or Tuesday, her mom was going to be released on Friday (10/5/18). She said, I am taking her back to assisted living. I have concerns about where she is and how it will go. She described her mom as being confused with anxiety. She said she did not know if the assisted living facility was able to provide the care her mom needed. Resident #75s daughter said she was concerned for her mom because she has had a major set-back with the last fall. She said she was trusting both facilities communicated her mom ' s needs with each other. The resident ' s daughter said she had hesitations of her mom returning to assisted living because her mom seemed uneasy and confused because of the accumulation of trauma. She said, again, she hoped the staff at this facility and the assisted living had communicated her mom ' s needs. The resident ' s daughter said she attended the care conferences but was not always clear of the discharge plan. She said she did not mention concerns because she did not know what questions she could ask and therefore did not. The facility failed to provide evidence a safe discharge plan was in place from the date of admission to 10/4/18 a day prior to discharge. The facility failed to provide evidence of communication with Resident #75s daughter, the accepting assisted living facility and ensure the assessments were completed for safety since the resident was a fall risk and this was her second admission to this facility for skilled rehabilitation because of falls at the assisted living.

Based on record review and staff interviews, the facility failed to ensure the services provided or arranged met professional standards of quality for one (#9) resident out of 16 sample residents reviewed. Specifically, the facility failed to: -Administer antibiotic therapy to Resident #9 prior to an indwelling catheter change as ordered; and -Change Resident #9s indwelling Foley catheter timely as ordered by the physician. Finding include: I. Resident #9 A. Resident #9 status Resident #9, age 88, was admitted [DATE] and readmitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/1/18 minimum data set (MDS) assessment revealed the resident ' s cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance of one person with toilet use and he had an indwelling catheter. B. Record review 1. Care plan The comprehensive care plan, revised 8/14/18, revealed the resident had a Foley catheter due to [MEDICAL CONDITION]. The interventions included, I take an antibiotic on days that my Foley catheter is changed and to change the catheter according to the physician's order [REDACTED]. 2. Physician orders The (MONTH) (YEAR) CPO revealed the following orders: -7/26/18: Bactrim DS (antibiotic) 800 -160 mg (milligrams), give one tablet by mouth as needed for [MEDICATION NAME] one hour before Foley catheter change. -9/14/18: Change catheter every 28 days for retention of urine. 3. Medication Administration Record [REDACTED] The (MONTH) (YEAR) TAR revealed the indwelling Foley catheter was changed on 8/17/18. According to the (MONTH) (YEAR) MAR, the Bactrim DS 800 -160 mg tablet was not administered on 8/17/18 prior to the catheter change as ordered. The (MONTH) (YEAR) TAR revealed the indwelling Foley catheter was changed on 9/26/18, 40 days after the last Foley catheter change and was not within the 28 days as ordered. The (MONTH) (YEAR) MAR indicated [REDACTED]. II. Staff interviews Registered nurse (RN) #2 was interviewed on 10/4/18 at 10:38 a.m. After review of the physician orders, she stated the Bactrim DS should have been administered prior to both catheter changes. She said the Foley catheter should have been changed at 28 days as ordered. She said these failures could increase the resident ' s risk for urinary tract infections. The director of nursing (DON) was interviewed on 10/4/18 at 1:30 p.m. After reviewing the physician orders [REDACTED]. She said these failures could increase the resident ' s risk for urinary tract infections and all physician orders [REDACTED].

Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one (#128) of two residents reviewed for person-centered care plans out of 16 sample residents. Specifically, the facility failed to ensure that Resident #128 ' s care plan was person-centered and addressed her behaviors. Findings include: I. Resident #128 A. Resident #128 status Resident #128, age 86, was admitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 9/15/18 minimum data set (MDS) assessment revealed the resident displayed short and long-term memory problems and her decision making ability was moderately impaired. She displayed verbal behaviors directed toward others four to six days out of seven and she rejected cares one to three days out of seven. She received an antipsychotic and antidepressant medication seven out of seven days. B. Record review 1. Physician orders Review of the (MONTH) (YEAR) CPO revealed the following orders: -9/30/18: Monitor and document any aggressive behaviors. -9/30/18: [MEDICATION NAME] (antipsychotic) 0.5 mg (milligram), give 0.5 mg by mouth one time a day for dementia with behaviors for seven days. -10/3/18: Monitor and record the following behaviors: Biting, hitting, striking out, continuous crying, continuous screaming or yelling, continuous pacing or wandering, danger to self, danger to others, extreme fear, hallucinations, delusions, paranoia, repetitive anxious verbalizations. -10/8/18: [MEDICATION NAME] 0.25 mg, give 0.25 mg by mouth two times a day for dementia with behaviors for seven days. -10/15/18:[MEDICATION NAME] 0.25 mg, give 0.25 mg by mouth daily for dementia with behaviors for seven days. 2. Behavior documentation Review of the (MONTH) (YEAR) and (MONTH) (YEAR) behavior tracking documentation on the MARs (medication administration record) revealed the resident did not display any behaviors. Review of the progress notes from 9/30/18 through 10/4/18 revealed the following behavioral concerns: The 9/12/18 physician progress notes [REDACTED]. (continue) [MEDICATION NAME] 0.5 mg BID (twice daily) for behaviors and hallucinations and supportive care. The 9/24/18 behavior note read, in pertinent part, At approximately 2330 (11:30 p.m.) Resident #128 was attempting to transfer herself from the recliner to w/c (wheel chair) by herself. A CNA (certified nurse aide) was attempting to assist her but Resident #128 was hollering at her. This nurse entered the room to try to redirect but unsuccessful. Resident #128 was cursing, attempted to hit and grab this nurse and was hollering for staff to get out of her house or she would call the cops. This nurse reminded her she just had hip surgery, voiced concern she may get hurt and asked if I may assist her. She shouted, (if you don ' t get the hell out of my house right now I ' ll stab you with a knife and fork!). The 9/29/18 behavior note read, in pertinent part, [MEDICATION NAME] taper completed today with last dose of 0.25 mg given this morning. Day shift reports resident spent up to an hour swearing at passers by. This evening resident repeatedly trying to transfer self. Resident observed crawling out of bed. Toileting and pain medication not reducing agitation. Resident denies pain. Vitals normal On call notified as order to notify provider of behaviors during taper. Orders received to give one time dose of [MEDICATION NAME] and chart behaviors. The 9/30/18 skilled nursing note read, in pertinent part, Was cursing at staff this morning and resisting care at times. Obtained ST (skin tear) to the back of her left hand. 3. Comprehensive care plan The comprehensive care plan, initiated 9/10/18, revealed the resident was newly admitted and she was unfamiliar with her environment. She had impaired cognitive function and impaired thought processes and she received an antidepressant medication. Staff were to administer the antidepressant medication as ordered and monitor for changes in behavior, mood, and cognition. The care plan failed to identify the resident received an antipsychotic medication ([MEDICATION NAME]). The care plan also failed to identify behavior concerns and/or person-centered interventions to reduce her behaviors. II. Staff interviews CNA #3 was interviewed on 10/4/18 at 10:15 a.m. She stated Resident #128 could be aggressive with staff and other residents. She said she would call for another person to help when the resident became aggressive. She stated the other person was usually able to calm her down. She was not aware of a location to find specific interventions to help calm the resident. She stated she would report behaviors to the nurse. Licensed practical nurse (LPN) #2 was interviewed on 10/4/18 at 10:45 a.m. She said aggressive behaviors should be identified on the resident ' s care plan along with interventions to help calm her. She said the nurses did not document anything on the care plans. She reported the MDS person created and updated the care plans. She said the nurses track the resident ' s behaviors on the behavior tracking on the MAR (medication administration record) or document the behavior in the progress notes. The social services director (SSD) was interviewed on 10/4/18 at 11:00 a.m. She said nursing was responsible for initiating and updating the care plan. The director of nursing (DON) was interviewed on 10/4/18 at 2:00 p.m. She said the facility did not currently have a MDS coordinator. She said the MDS coordinator ' s last day was the previous week and both she and the unit managers were responsible for initiating and updating the residents ' care plans. She said Resident #128s care plan should address her aggressive behaviors and should include person-centered approaches.

Based on observations, record review and interviews, the facility failed to promote self-determination for one (#12) of one residents out of 16 sample residents reviewed for preferences and choices. Specifically, the facility failed to: -Communicate and honor Resident #12s preferences regarding wake up times (when the resident wanted to get up for the day). Findings include: A. Resident status Resident #12, age 91, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 8/3/18 minimum data set (MDS) assessment the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident interview for daily preferences documented it was very important for her to choose her own bedtime. The resident requires extensive assistance with one person for bed mobility, transfers, and locomotion on and off the unit, dressing, toilet use and personal hygiene. B. Resident interviews Resident #12 was interviewed on 10/1/18 at 1:12 p.m. She said the staff were kind of pushy when it came to wake up times. She said they entered the room and said it was time to get dressed. The resident said she normally would wake up about 8:00 in the morning when she lived at home. She said the staff get her up about 7:00 in the morning. During a follow-up interview with the resident on 10/3/18 at approximately 9:45 a.m. She said she would like to get up about 8:00 in the morning. She said she had complained to the certified nurse aides (CNAs) at times and the staff told her she had to get up to eat breakfast. C. Record review The residents care plan failed to identify the resident's preference for wakeup times. The admission assessment completed on 6/11/18 at 3:38 p.m. documented the resident had trouble falling asleep and her usual bedtime varied. The assessment documented the resident's usual waking time was 8:00 a.m. D. Observations The resident was observed continuously on 10/3/18 from 7:02 a.m. until 7:38 a.m. She was reclined in her bed with her eyes closed at 7:02 a.m. A female staff entered the room at 7:15 a.m. the staff person exited the room at 7:28 a.m. The resident was sitting in her recliner with her eyes closed, her head fell forward and down to her chin, she leaned to the left and then back into the recliner at 7:32 a.m. The resident was observed on 10/4/18 at 7:16 a.m. She was in the dining room at the table with two other residents. She told the other residents she was tired and wanted to go back to bed. She said she was not used to being up so early. E. Staff interviews Certified nurse aide (CNA) #6 was interviewed on 10/4/18 at 8:03 a.m. He said residents had choices of when to get up, go to bed, take showers and attend activities. He said the residents were asked a lot of questions upon admission and the information was transferred to the care plan for routine care. He said he asked newly admitted residents what their preferences were while he provided care. CNA #6 did not know what Resident #12s preference time was to wake up in the morning. The CNA said the resident was able to tell the staff what her preferences were. Registered nurse (RN) #2 was interviewed on 10/4/18 at 3:19 p.m. She said the residents were asked what their daily routine and preferences were upon admission. She said the admission assessment included usual time to get up and go to bed. She said the information was listed in the CNAs tasks and it should have been honored. The RN said Resident #12 liked to get up between 7:00 and 7:30 a.m. to eat in the dining room and other times she liked to eat in her room. She said the resident was able to tell the staff when she wanted to get up in the morning. The director of nursing (DON) was interviewed on 10/4/18 at 4:07 p.m. She said the residents preferences were identified and documented in the admission assessment. The information was transferred to the residents care plan. The DON said the facility staff communicated resident preferences verbally and also reviewed the care plan to ensure they followed the resident wishes. The DON said the resident's preferences was to wake up at 8:00 a.m. should have been honored. She said the staff should not wake her before unless she requested a different time.

Based on observations, record review and staff interviews, the facility failed to develop and implement a baseline care plan for two (#129 and #75) of two residents reviewed for baseline care plans out of 16 sample residents. Specifically, the facility failed to: -Identify pressure ulcers and pressure ulcer prevention interventions on Resident #129s baseline care plan. -Develop and implement a resident specific baseline care plan within 48 hours of Resident #75s admission. Findings include: I. Facility policy and procedure The Skin Integrity Clinical Standard policy and procedure, undated, provided by the nursing home administrator on 10/4/18, read, Care plan will reflect current interventions for skin integrity issue and include preventive measures. II. Resident #129 A. Resident #129 status Resident #129, over the age of 85, was admitted [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. The 9/30/18 Admission Nursing Tool revealed the resident displayed short and long-term memory problems. She required the assistance of two people with transfers and was non-ambulatory. The skin assessment revealed a suspected deep tissue injury (DTI) on her right heel which measured 1.0 cm (centimeters) x (by) 2.0 cm. The left heel had a DTI which measured 1.5 cm x 1.0 cm. B. Record review 1. Physician orders The (MONTH) (YEAR) CPO revealed the following orders: -9/30/18, Monitor purple, non-blanchable discoloration to left heel until resolved. -9/30/18, Monitor purple, non-blanchable discoloration to right heel until resolved. -10/1/18, Skin prep to bilateral heels every shift and as needed (PRN). -10/1/18, Elevate heels as tolerated while in bed. 2. Care plan The baseline care plan, initiated 10/2/18, revealed the resident was admitted for a short stay, skilled rehabilitation services. She received anticoagulant and diuretic therapy. She was incontinent of bowel. Staff were to perform skin checks per protocol and to report abnormalities to the nurse. -The care plan failed to identify the resident was admitted with DTIs to her bilateral heels and the physician order [REDACTED]. The certified nurse aide (CNA) kardex failed to identify the actual skin breakdown on the residents heels and failed to identify the physician ordered intervention to elevate her heels while in bed. C. Staff interviews CNA #2 was interviewed on 10/4/18 at 10:30 a.m. He stated he was the primary CNA for Resident #129. He stated the resident did not have any skin breakdown or concerns and she did not require any interventions to prevent skin breakdown. He said the nurse would notify him of any changes in skin condition or interventions needed at the beginning of the shift. Registered nurse (RN) #2 was interviewed on 10/4/18 at 10:45 a.m. She stated the resident had deep tissue injuries on both of her heels and skin prep was being applied daily. She said staff should elevate her heels when she was in bed. She said the care plan should reflect the DTI ' s to her heels and provide staff with preventive interventions. The director of nursing (DON) was interviewed on 10/4/18 at 1:00 p.m. She said the baseline care plan should reflect the DTI ' s on the resident ' s heels. She said the care plan and CNA kardex are used to communicate care needs to the staff. She said the care plan and Kardex should provide staff with instructions to elevate her heels when she is in bed as ordered. III. The facility failed to develop and implement a resident specific baseline care plan within 48 hours of Resident #75s admission. A. Resident status Resident #75, age 76, was admitted on [DATE] and readmitted [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The resident did not have an admission assessment completed in the records. B. Failure to implement a resident specific care plan The care plan initiated 9/24/18 read, My final wishes are and I request a code status of full code had an X next to it. The intervention was: where possible review code status quarterly. The care plan initiated 9/25/18 and revised on 9/25/18 identified the resident was receiving rehab therapy specified physical therapy, occupational therapy and speech therapy. Interventions were not included for the identified problem. The care plan, initiated 9/24/18 read, I have an ADL self-care performance deficit. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I have limited physical mobility. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I have an ADL self-care performance deficit. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I wish to (SPECIFY return/be discharged ) to (SPECIFY home, another facility). The problem identified did not include specific details about discharge. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I am a high risk for falls. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/2/18 read, I use an antidepressant medication. [MEDICATION NAME]. The problem identified was not resident specific as to why the resident was administered an antidepressant. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I have (SPECIFY acute or chronic pain). The problem identified was not resident specific as to the type of pain or location. Interventions were not resident specific. The care plan, initiated 9/24/18 read, I have potential or actual impairment to skin integrity. The problem identified was not resident specific. Interventions identifying specific needs were not included for the identified problem. The care plan, initiated 9/24/18 read, I have impaired visual function. The problem identified did not include specific deficits. Interventions identifying specific needs were not included for the identified problem. C. Staff interviews The Social services director (SSD) was interviewed on 10/3/18 at 5:00 p.m. She said the 48 hour baseline care plan should be initiated upon admission. She said she did not complete the care plan for the resident. The SSD said nursing staff was responsible for the residents 48 hour baseline care plan. She said the resident nurse manager (RNM) was helping out with care plans because the minimum data set (MDS) coordinator had resigned recently. The RNM was interviewed on 10/4/18 at 10:28 a.m. She said social services and the MDS coordinator initiated the resident care plans on admission. She said the care plan should identify the problems, include a goal and interventions. The RNM reviewed Resident #75's care plan and said it was not complete. She said the care plan should have been more specific to the resident and her needs. The RNM said it was important to have the 48 hour care plans because that was how care was directed for the resident. She said she was trying to keep up since the MDS coordinator resigned recently.