Every finding on record at The Center at Cordera

Based on observations, record review and interviews, the facility failed to ensure staff provided respiratory care consistent with professional standards of practice for one (#40) of two residents reviewed for respiratory services out of 29 sample residents.Specifically, the facility failed to ensure there was a physician's order in place for Resident #40's bilevel positive airway pressure (BIPAP) machine and routine maintenance of the BiPAP.Findings include:I. Professional referenceAccording to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 7/29/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/, Devices such as high flow oxymasks, CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), or mechanical ventilation may be initiated by the respiratory therapist or provider to deliver higher amounts of inspired oxygen. (Chapter 11) Manage oxygen therapy and equipment: If the patient is already on supplemental oxygen, ensure the equipment is turned on, set at the required flow rate, correctly positioned on the patient, and properly connected to an oxygen supply source. If a portable tank is being used, check the oxygen level in the tank. Ensure the connecting oxygen tubing is not kinked, which could obstruct the flow of oxygen. Feel for the flow of oxygen from the exit ports on the oxygen equipment.II. Facility policy and procedureThe Respiratory Equipment policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 7/28/26 at 1:15 p.m. It read in pertinent part, The resident will receive necessary respiratory care and services in accordance with professional standards of practice, the resident's orders and care plan and the resident's choice. The resident will have an order that includes settings when indicated (for CPAP/BiPAP). Respiratory equipment will be cleaned and stored according to manufacturer's guidelines. III. Resident #40A. Resident statusResident #40, age [AGE], was admitted on [DATE]. According to the July 2026 computerized physician orders (CPO), diagnoses included obstructive sleep apnea, hypertension, and dependence on supplemental oxygen.The 7/22/26 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. The resident used a motorized wheelchair. She was independent with eating and dependent with toileting. She required substantial to maximum assistance with showers and supervision, or touch assistance, with personal hygiene.The MDS assessment revealed Resident #40 used a BiPAP machine and was on supplemental oxygen.B. ObservationsOn 7/27/26 at 9:13 a.m. Resident #40 was sitting in her motorized wheelchair in her room on the east side of her bed. Resident #40's BiPAP machine was positioned on her bedside drawer, with a mask and with the tubing connected to the BiPAP. The part of the BiPAP mask that connected to the resident's nose was lying on top of the bedside drawer without a protective cover. Laying beside the BiPAP and the mask was a plastic storage bag.-However, the mask was not being stored in the protective storage bag.On 7/27/26 at 4:30 p.m. Resident #40's BiPAP mask was on the bedside drawer next to the BiPAP machine. The mask was lying on top of a puzzle and was not contained in a storage bag.On 7/28/26 at 11:20 a.m. Resident #40's BiPAP machine remained in the same position on top of the bedside drawer. The tubing and the mask were connected to the BiPap machine and the mask was hanging beside the drawer. The plastic protective storage bag was on top of the bedside drawer.-However, the mask was not stored in the protective storage bag.C. Resident interviewResident #40 was interviewed on 7/27/26 at approximately 2:00 p.m. Resident #40 said she used her BiPAP machine every night for sleep and received assistance from the facility staff to set up the device. She said nursing staff assisted her by ensuring the machine was turned on and properly connected to supplemental oxygen at a flow rate of 1 liter per minute (LPM). Resident #40 said when her BiPAP machine was not in use during the day, the staff usually left her BiPAP mask resting on top of her bedside drawer without using a protective storage cover or bag. Resident #40 said no facility staff member had cleaned, sanitized, or performed maintenance on her BiPAP machine, mask, or tubing since her admission to the facility (on 7/13/26). D. Record review-Review of Resident #40's July 2026 CPO revealed no physician's order for the use of the BiPAP and no instructions for maintenance and cleaning of the device.The respiratory care plan, initiated 7/14/26, revealed Resident #40 was at respiratory risk related to deficiencies/abnormalities in pulmonary function and sleep apnea. Interventions included CPAP use according to physician's orders, monitoring the resident's pulse oximetry (level of oxygen in the blood) every shift and if it was less than 88%, starting oxygen at 1 to5 LPM continuously. -The care plan failed to include the use of the BiPAP machine (instead of a CPAP machine) or instructions for the cleaning/maintenance of the equipment.IV. Staff interviewsRegistered nurse (RN) #2 was interviewed on 7/23/26 at 2:58 p.m. RN #2 said upon admission, all medical equipment brought into the facility by a resident was required to be documented in the resident's electronic medical record (EMR) RN #2 said the necessary physician's orders were to be obtained for any device requiring medical oversight. RN #2 said Resident #40 used a BiPAP machine; however, she could not find physician's orders for the use and maintenance of the BiPAP machine.RN #1 was interviewed on 7/27/26 at 3:35 p.m. RN #1 said Resident #40 used a BiPAP machine at night. RN #1 said facility staff were responsible for obtaining physician's orders for all medical equipment. She said she could not find a physician's order for BiPAP administration and routine maintenance in Resident #40's EMR. RN #1 said it was important to obtain physician's orders for the administration and maintenance of the BiPAP to ensure proper settings.The director of nursing (DON) was interviewed on 7/27/26 at 4:06 p.m. The DON said all medical equipment brought into the facility by residents upon admission required a physician's order. The DON said the staff should notify the physician and obtain a physician's order for the administration and maintenance of BiPAP/CPAP machines. She said BiPAP use and maintenance should be included in the resident's care plan. The DON said Resident #40 used a BiPAP machine at night; however she did not know why the staff had failed to obtain a physician's order for the administration and maintenance of the resident's equipment. The DON said failing to obtain a physician's order for a BiPAP machine could lead to significant adverse effects for the resident, including improper pressure delivery, hypoventilation (breathing too slowly or too shallowly, causing a harmful buildup of carbon dioxide), inadequate oxygenation, and an increased risk of severe respiratory infections caused by unmaintained or improperly sanitized equipment. The DON said she would provide immediate education to all licensed nursing staff regarding the facility's respiratory care and medical equipment policies. The DON said she would immediately contact the physician to obtain complete physician's orders for the administration settings, routine cleaning and maintenance, and proper hygienic storage of Resident #40's BiPAP machine.

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications for two of two medication storage rooms and one of three medication carts.Specifically, the facility failed to:-Ensure expired medications were disposed of; -Ensure medications were contained in the original packaging; and,-Ensure the controlled medication box was permanently affixed in the medication storage room refrigerator.Findings include:I. Professional referenceAccording to the United States (U.S.) Food and Drug Administration guidelines, dated 10/31/24, retrieved on 7/29/26 at 9:00 a.m. from https://www.fda.gov/drugs/safe-disposal-medicines/dont-be-tempted-use-expired-medicines, In 1979, the U.S. Food and Drug Administration began requiring an expiration date on prescription and over-the counter medicines. The expiration date is a critical part of deciding if the product is safe to use and will work as intended. The expiration date can be found printed on the label or stamped onto the bottle or carton. It is important to know and stick to the expiration date on your medicine. Using expired medicines is risky and possibly harmful to your health. Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it. According to the Drug Enforcement Administration (DEA), failing to safely dispose of old medications can cause harm if taken by mistake.II. Facility policy and procedureThe Medication Storage policy and procedure, revised 1/29/25, was provided by the nursing home administrator (NHA) on 7/28/26 at 12:35 p.m. It read in pertinent part, Ensure safe, secure, and compliant storage of medications. All medications are stored in locked carts and medication rooms. All controlled substances are stored in a double-locked system under advisement of facility pharmacy. For over-the-counter medications in bulk, the label contains the original manufacturer's medication name, strength, quantity, accessory instructions, lot number, and expiration date. The facility ensures that medication labeling in response to order changes is accurate and consistent with applicable state requirements. Multi-dose vials are dated upon opening and discarded upon the date designated by the manufacturer. Expired medications are removed; Bulk over-the-counter products that remain in the manufacturer's original container can be used until the manufacturer's expiration date, noted on the product label. Expired/discontinued medications are segregated in designated bins/areas.III. Observations and staff interviewsOn 7/27/26 10:24 a.m. the #2 South medication cart and the medication storage room were observed with licensed practical nurse (LPN) #1. The following items were found: -The medication refrigerator was unlocked and contained three multi-use vials of sodium chloride injection 0.9%. One vial was open but was not dated and all three vials had expired in August 2025.-One foil medication card containing four bisacodyl 10 milligram (mg) suppositories and one foil wrapped hemorrhoidal suppository were in the top drawer of the medication cart and were not contained in the original packaging.LPN #1 said the nurses were supposed to review the medication carts for expired medications and remove them. She said central supply monitored and stocked over-the-counter medications in the medication room. She said the pharmacist made routine visits to the facility to go through the medication carts to remove any expired or loose medications. She said she did not know when the pharmacist had been at the facility last.On 7/27/26 at 10:30 a.m. the third floor medication room was observed with the director of nursing (DON). The following items were found:-The medication refrigerator was unlocked and on the top shelf inside the door, there was a black metal box that contained lorazepam (a schedule IV controlled substance) provided by the pharmacy. The box was not permanently affixed inside the refrigerator. -Nine elastomeric pump devices (small, disposable, non-electric medical devices used to deliver intravenous (IV) medications, such as antibiotics) were in the bottom drawer of the medication refrigerator. The devices contained Daptomycin (antibiotic) 700 mg/100 milliliters (ml). The medication had been dispensed from the pharmacy on 5/26/26 with instructions to discard the medication after 6/5/26. The DON said when the physician's order for the refrigerated IV antibiotic medication was discontinued on 6/4/26 and was not to be used after 6/5/26, staff failed to discard the expired medication. She said any expired or discontinued medications were to be discarded to ensure staff did not use them. She said expired medications were not to be used because of the potential for diminished effectiveness or adverse reactions. She said the floor nurses and management staff were responsible for reviewing the medication carts and the medication refrigerators routinely to discard expired or discontinued medications. The DON said the medication refrigerators should be locked because all nurses had a key for them. She said the black box in the refrigerator was provided by the pharmacy but she did not know that it needed to be permanently affixed inside the refrigerator. The DON said since the refrigerator was unlocked and the black box was not permanently affixed inside, she agreed that anyone could remove the box from the refrigerator. She said if a nurse needed to administer the lorazepam, the nurse had to obtain the key from the emergency medication machine to open the box. She said the pharmacist made routine visits to the facility to review the medication carts and she thought the pharmacist reviewed the refrigerators as well. She said the pharmacist had been at the facility recently but she did not recall the exact date. IV. Facility follow upOn 7/28/26 at 2:14 p.m. the NHA provided a copy of a work order from the maintenance department. The work order indicated that on 7/28/26, a chain and lock had been installed on the black box that affixed it to the inside of the third floor medication storage room's medication refrigerator to prevent the potential of someone removing the box. -However, the black box was not permanently affixed inside the medication refrigerator until after it was brought to the facility's attention during the survey on 7/27/26 (see observation above).

Based on record review and interviews, the facility failed to ensure one of five nursing members were able to demonstrate skills and techniques necessary to care for residents' needs.Specifically, the facility failed to ensure licensed practice nurse (LPN) #1 was licensed in Colorado while working active shifts at the facility. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from [DATE], resulting in the deficiency being cited as past noncompliance with a correction date of [DATE]. I. Facility correctionA. Immediate actionThe human resources manager, while completing license verification checks on [DATE], identified LPN #1's expired multi-license nursing license. Upon notification of LPN #1 no longer having a multistate license, LPN #1 was notified and placed on suspension. LPN #1's employment status was terminated. The executive director and human resources manager spoke with LPN #1 and she said she would notify both her Texas Board of Nursing and the Colorado Board of Nursing of the concern.B. Identification of othersOn [DATE] and [DATE] the director of nursing (DON) completed a license check of all currently employed licensed nursing personnel to ensure each employee held an active license appropriate for their position and was authorized for practice in the state of Colorado or under valid nurse licensure compact multistate privileges. No issues were identified. C. Systemic changesThe facility revised the onboarding and credential verification process to require primary source verification of all professional licenses prior to any employee performing duties in a licensed capacity.The facility human resources manager was no longer employed. The NHA and DON were overseeing monthly license checks to ensure they were completed timely and if issues were identified they were addressed immediately.D. MonitoringAll newly hired licensed personnel will have primary source license verification completed prior to working in a licensed role to ensure licensing requirements are met. Compliance with license verification requirements will be monitored monthly via routine personnel file review processes to ensure continued adherence to credentialing standards. This will be the responsibility of the human resources manager. Upon hire of a new human resources manager, she/he will be re-trained on the expectation of monthly license checks and immediate notification of the NHA, DON and regional human resources director of any license concerns.The facility has since strengthened their internal processes for license monitoring to prevent any recurrence by ensuring license checks are completed monthly. The facility implemented Nursys e-Notify enrollment for all currently employed and newly hired licensed nurses to establish a standardized primary-source verification process. This would be completed at the time of hire and continuously monitored thereafter. Nursys is a verification system maintained by the National Council of State Boards of Nursing (NCSBN) that provides direct primary-source confirmation of licensure status, participating-state licensure eligibility, and publicly reported disciplinary or administrative actions. Enrollment of licensees in Nursys e-Notify enables real-time notifications of changes to licensure status, including expiration, discipline, restrictions, limitations, or other actions that may impact the nurse's ability to practice, allowing the facility to respond promptly and ensure ongoing compliance with regulatory requirements for verifying active, unrestricted licensure.II. Record reviewThe employee file for LPN #1 was reviewed on [DATE] at 12:50 p.m. The initial license check verification, completed on [DATE] at 2:29 p.m., documented LPN #1 had a multi-state license which included Colorado, which expired on [DATE].A license verification check ran on [DATE] at 12:50 p.m. documented LPN #1 had a valid single state nursing license for the state of Texas.LPN #1's punch details documented she worked shifts at the facility after the multi state license expired on [DATE] from 6 p.m. to 12:30 a.m., [DATE] from 5:50 a.m. to 12:45 p.m. and [DATE] from, 5:50 a.m. to 7:30 p.m.LPN #1's termination paperwork documented her employment was terminated on [DATE].III. Staff interviewsThe NHA was interviewed on [DATE] at 1:48 p.m. The NHA said the human resources manager was responsible for conducting license verification checks every month for every nurse who worked at the facility, which included as needed nurses. He said the human resources manager was responsible for ensuring nurses who did not have a valid nursing license did not work shifts at the facility.The NHA said LPN #1 was hired as a nurse with a valid multi state nursing license, which originated from Texas. He said LPN #1's multi state nursing license expired on [DATE]. He said LPN #1 had a current valid nursing license for the state of Texas. He said LPN #1 worked three shifts at the facility after her multi-state nursing license expired.The NHA said the human resources manager told him LPN #1's license verification fell through the cracks and she did not check her license after [DATE]. He said the human resources manager resigned from her position at the facility.The NHA said the facility was in the process of hiring a new human resources manager. He said the facility identified the human resources manager was not printing off the license verifications to show the license verifications were being completed.The NHA said the facility put a new system in place to ensure all nurse license verifications would be monitored each month.

Based on observations, interviews, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards for four residents (#8, #2, #9 and #5) of eight out of 12 sample residents.Specifically, the facility failed to ensure oxygen was administered according to physician's orders for Resident #8, #2, #9 and #5. Findings include: I. Professional Reference According to Nursing Skills, Open Resources for Nursing (Open RN); Ernstmeyer K, [NAME] E, editors. Eau [NAME] (WI): [NAME] Valley Technical College; published 2021, accessed on 2/18/26 from https://www.ncbi.nlm.nih.gov/books/NBK593208/ Oxygen is considered a medication and, therefore, requires a prescription and continuous monitoring by the nurse to ensure its safe and effective use. (Chapter 11) For patients with chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), the target range for SpO2 is often lower at 88% to 92%. (Chapter 11) Oxygen is a medication and should not be adjusted without consultation with a physician or respiratory therapist. (Chapter 11) FiO2 (oxygen concentration) levels should be decreased as soon as feasible to do so to prevent lung injury. (Chapter 11) III. Resident #8 A. Resident status Resident #8, age [AGE], was admitted on [DATE]. According to the February 2026 computerized physician's orders (CPO), diagnoses included cellulitis of the left lower limb, acute respiratory failure with hypoxia, mild intermittent asthma, and obstructive sleep apnea. The 12/30/25 minimum data set (MDS) assessment revealed the resident was cognitively intact, with a BIMS score of 15 out of 15. Resident #8 was on continuous oxygen and needed partial assistance with ADLs B. Observations On 2/3/26 at 5:09 p.m. Resident #8 was sitting in his wheelchair watching television. He was wearing a nasal cannula and his oxygen was set to 4 liters per minute (LPM). On 2/4/26 at 8:50 a.m. Resident #8's oxygen was set to 4 LPM. On 2/5/26 at 9:03 a.m. Resident #8's oxygen was set to 4 LPM. C. Resident interview Resident #8 was interviewed on 2/3/26 at 5:09 p.m. Resident #8 said he did not wear oxygen prior to his hospitalization. Resident #8 said he did not understand how the staff knew he needed oxygen. He said he did not know what the rate was set to. D. Record review Review of the February 2026 CPO revealed the following physician's orders: Monitor pulse oximeter every shift, ordered 12/26/25. Oxygen therapy at 1 to 5 LPM continuously through a nasal cannula. Titrate oxygen saturation to greater than or equal to 88%, ordered 12/26/25. The oxygen care plan, dated 12/26/25, documented the resident was at respiratory risk related to respiratory conditions. Interventions included administering oxygen as ordered and as needed, notifying the physician of a change in status, and monitoring the pulse oximeter every shift and if less than 88% oxygen saturation to start oxygen at 1 to 5 LPM continuously, to titrate O2 saturation to greater than or equal to 88%. The hospital Discharge summary, dated [DATE], documented Resident #8 was on 1 LPM of oxygen at the time of discharge. The comprehensive nursing admission data, dated 12/25/25, documented Resident #8 was on 1 LPM of oxygen at admission. The vital sign record on 12/25/25 documented Resident #8's oxygen saturation at 92% and 95%. Resident #8's December 2025 MAR documented Resident #8 was on 3 LPM of oxygen starting on 12/26/25. -However, there was no documentation indicating the resident needed more oxygen based on the documented oxygen saturations (see observations above). D. Staff interviews Registered nurse (RN) #4 was interviewed on 2/4/26 at 4:43 p.m. RN #4 said she was Resident #8's nurse. She said she was an agency nurse and had not worked with Resident #8 before. RN #4 said she was not told what Resident #8's baseline oxygen needs were, nor was the information on the report sheet shared with the nurses. RN #4 said Resident #8's oxygen saturation was 97% on 4.5 LPM, so she did not have to titrate the LPM down. RN #4 said the physician's order was to titrate the oxygen from 1 to5 LPM, so she did not need to call the physician or decrease the oxygen flow rate. IV. Resident #2 A. Resident status Resident #2, age 8, was admitted on [DATE]. According to the February 2026 CPO, diagnoses included acute cystitis without hematuria, urinary tract infection, interstitial pulmonary disease, and chronic respiratory failure with hypoxia. The 2/4/26 admission note documented the resident was fully alert and oriented, and cognitively intact. Resident #2 used a wheelchair for mobility and supplemental oxygen continuously. B. Observations On 2/5/26 at 9:10 a.m. Resident #2 was lying in bed with a nasal cannula on and her oxygen was set to 4 LPM. C. Resident interview Resident #2 was interviewed on 2/5/26 at 9:10 a.m. Resident #2 said her baseline oxygen was 3 LPM. D. Record review Review of the February 2026 CPO revealed the following physician's orders: Monitor pulse oximeter every shift, ordered 2/4/26. Oxygen therapy at 1 to 5 LPM continuously through a nasal cannula to titrate oxygen saturation to greater than or equal to 88%, ordered 2/4/26. The oxygen care plan, dated 2/4/26, revealed the resident was at respiratory risk related to respiratory conditions. Interventions included administering oxygen as ordered and as needed, notifying the physician of a change in status, and monitoring the pulse oximeter every shift and if less than 88% oxygen saturation to start oxygen at 1 to 5 LPM continuously, to titrate O2 saturation to greater than or equal to 88%. Resident #2's hospital Discharge summary, dated [DATE], revealed Resident #2 was on 3 LPM of oxygen at the time of discharge. -However, there was no documentation indicating the resident needed more oxygen based on the documented oxygen saturations (see observations above). D. Staff interviews Registered nurse (RN) #6 was interviewed on 2/5/26 at 9:12 a.m. RN #6 said Resident #2 was on 4 LPM of oxygen at the start of her shift in the morning. RN #6 said Resident #2's oxygen saturation was at 99% when her vital signs were checked in the morning. RN #6 said Resident #2 was admitted overnight, so she did not know how much oxygen Resident #2 should be on. RN #6 said nurse practitioner (NP) #1 had reduced Resident #2's oxygen LPM because her saturation was good and Resident #2's baseline oxygen was 3 LPM. -However, observations revealed Resident #3 was receiving 4 LPM (see observations above). VI. Staff training Staff training documentation was provided by the DON on 2/5/26 around 2:30 p.m. The trainings related to oxygen therapy included how to initiate oxygen therapy, and when to change tubing. -However, the training did not include when to notify the provider of a change in oxygenation, and how to appropriately titrate oxygen flow rate to maintain oxygen saturation within the residents' physician ordered parameters. On 2/6/26 the NHA emailed documentation at 12:21 p.m. (after the survey exit), the facility had received education on oxygen titration. VII. Additional staff interviews RN #4 was interviewed on 2/4/26 at 4:43 p.m. RN #4 said oxygen was considered a medication and must have a physician's order. RN #4 said most residents had a standing order to titrate oxygen from 1 to 5 LPM to keep oxygen saturation above 88%. RN #4 said if a resident's oxygen saturation was low she would increase the oxygen, but typically the provider would place an additional order to titrate the oxygen flow rate down. RN #4 said she has not had to titrate anyone off oxygen. RN #5 was interviewed on 2/4/26 at 5:34 p.m. RN #5 said oxygen was a medication and needed a physician's order to be given. RN #5 said the nursing staff typically communicated residents' oxygen needs on the report sheet, however the report sheet had not been updated in a few weeks. RN #5 said if she needed to know how much oxygen a resident needed, then she would look in the resident's hospital discharge record. The director of nursing (DON) was interviewed on 2/4/26 at 6:27 p.m. The DON said nursing staff were expected to document any change in oxygen flow rate in the vital signs log of the residents' medical charts. The DON said nurses did not need to notify the provider of a change in oxygen flow rate, unless the rate was higher than the 5 LPM specified in the standing order for all residents. The DON said oxygen was a medication, and nurses could use their nursing judgement to titrate the flow rate appropriately. The DON said the facility would usually wean residents off oxygen as they approached their discharge date . NP #1 was interviewed on 2/5/26 at 1:29 p.m. NP #1 said the standing physician order for most residents was to titrate their oxygen from 1 to 5 LPM to maintain an oxygen saturation greater than or equal to 88%. NP #1 said the order was written so nursing staff could titrate the oxygen to an appropriate flow rate for the residents' needs. NP #1 said the oxygen saturation goal for most residents was 90% or better. NP #1 said she preferred residents' saturation levels to be kept around 90% to use the least amount of supplemental oxygen which was especially important for residents with COPD because of the increased risk for hyper-oxygenation and CO2 retention. NP #2 was interviewed on 2/5/26 at 2:02 p.m. NP #2 said all residents had the same physician's order to titrate from 1 to 5 LPM of oxygen to maintain oxygen saturation at or above 88%. NP #2 said the standard protocol was for nursing staff to notify the provider of any change in oxygen titration. NP #2 said residents should be weaned off oxygen as soon as they could, especially in the case of COPD. VII. Resident #9 A. Resident status Resident #9, age [AGE], was admitted on [DATE]. According to the February 2026 CPO, diagnoses included COPD. The 12/24/25 MDS assessment revealed the resident was cognitively intact, with a BIMS score of 15 out of 15. The MDS assessment indicated the resident used oxygen. B. Observations On 2/4/26 at 10:00 a.m. Resident #9's oxygen was set at 3.5 LPM of oxygen being administered via a nasal cannula. On 2/4/26 at 5:30 p.m. Resident #9's oxygen was set at 3.5 LPM of oxygen being administered via a nasal cannula. C. Record review Review of the February 2026 CPO revealed the following physician's order: Oxygen therapy 1 to 5 LPM through nasal cannula may titrate to greater than or equal to 88% every shift and PRN (as needed). Okay for therapy to titrate, ordered 12/7/25. Check oxygen saturation twice a day, ordered 12/7/25 The oxygen care plan, dated 12/23/25, revealed the resident was at respiratory risk related to respiratory conditions, COPD and obstructive sleep apnea. Pertinent interventions included administering oxygen as ordered and as needed. Review of Resident #9's electronic medical record (EMR) the resident's oxygen level remained above 93% between 1/1/26 to 2/4/26. Review of Resident #9's EMR did not reveal documentation of oxygen administration being omitted or titrated to a lower level when the resident's oxygen levels were within the appropriate range. D. Staff interviews RN #1 was interviewed on 2/4/26 at 5:20 p.m. RN #1 said Resident #9 was on oxygen continuously for COPD. She said the resident was at 2.5 LPM. -However, observations revealed the resident was on 3.5 LPM (see observations above). RN #1 said the oxygen orders were generic batch orders. RN #1 said that if the resident's oxygen level was below 88% oxygen saturation, she would titrate her oxygen up by one liter per minute until the resident's oxygen level was above 88% oxygen saturation. She said she would check the resident's oxygen as she was increasing her oxygen. RN #1 said she checked Resident #9's oxygen and said it was set at 3.5 LPM. She said no one told her the flow was increased. RN #1 said was going to discuss this with the other nurses to ensure all nurses were on the same page with oxygen for the residents. VIII. Resident #5 A. Resident status Resident #5, age [AGE], was admitted on [DATE]. According to the January 2026 CPO, diagnoses included COPD. The 1/23/26 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The MDS indicated the resident used oxygen. B. Observations On 2/4/26 at 3:00 p.m. Resident #5 was in her room with a nasal cannula on. On 2/5/26 at 10:00 a.m. Resident #5 was in her room with a nasal cannula on. C. Record review Review of the February 2026 CPO revealed the following physician's order: Oxygen to be on at 1 to 5 liters per minute (continuously), delivered through nasal cannula. May titrate to greater than or equal to 88% every shift and as needed. Okay for therapy to titrate, ordered 1/10/26. Check oxygen saturation twice a day, ordered 1/10/26. The oxygen care plan, dated 1/23/26, revealed the resident was at respiratory risk related to respiratory conditions, COPD and malignant neoplasm of bronchus and lung. Pertinent interventions include administering oxygen as ordered and as needed. Review of Resident #5's EMR revealed the resident's oxygen was above 93% between 1/11/26 to 2/5/26. Review of Resident #5's EMR did not reveal documentation of oxygen administration being omitted or titrated to a lower level of liters per minute when oxygen levels were within the appropriate range. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 2/5/26 at 5:30 p.m. LPN #1 said she reviewed Resident #5's EMR and said the resident was on oxygen for COPD. LPN #1 said the oxygen level was checked twice a day. He said when oxygen was titrated he did not call the physician when oxygen flow was changed because the order provided a range and the nurses were able to work within the range. LPN #` said he currently relied on cross over reports and medication administration passes to observe the resident and the flow the resident was set on. LPN #1 said Resident #5 was on oxygen. He said he did not know how many liters she was on.

Based on observations, record review and interviews, the facility failed to ensure self-administration of medications was clinically appropriate for three (#3, #8 and #13) of three residents out of 21 sample residents.Specifically, the facility failed to: -Ensure Resident #3, Resident #8 and Resident #13 were assessed for the appropriateness and safety of self-administration of medications;-Ensure there was a physician order for self-administration of medications; and,-Ensure there was a physician order for medications at the bedside for Resident #8 and Resident #13.Findings include: I. Facility policy and procedure The Self-administration of Medications policy, dated [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 2:09 p.m. It read in pertinent part, “The nursing staff will assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. If the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident’s medications.” “The nursing staff will document their findings and the choices of residents who are able to self-administer medications. The nursing staff will routinely check self-administered medications and will remove expired, discontinued, or recalled medications. Nursing staff will review the self-administered medication record on each nursing shift, and they will transfer pertinent information to the medication administration record (MAR) kept at the nursing station, appropriately noting that the doses were self-administered.” II. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (air flow blockage), acute and chronic respiratory failure (decrease in the ability to bring oxygen into the bloodstream) and dysphagia (difficulty swallowing). A minimum data set (MDS) assessment had not been completed at the time of the survey. According to the resident’s nursing comprehensive admission data collection, dated [DATE], the resident was alert and oriented to person, place, time and situation. The resident required supervision for activities of daily living (ADL). B. Observations and resident interview On [DATE] at 5:20 p.m. an albuterol sulfate inhaler with a spacer was observed on Resident #3’s bedside table. Resident #3 said the albuterol sulfate inhaler with the spacer was her rescue inhaler. She said the frequency she used the rescue inhaler depended on the day. On [DATE] at 11:15 a.m. an albuterol sulfate inhaler with a spacer was observed on Resident #3’s bedside table. On [DATE] at 3:12 p.m. an albuterol sulfate inhaler with a spacer was observed on Resident #3’s bedside table. On [DATE] at 5:30 p.m., an albuterol sulfate inhaler with a spacer was observed on Resident #3’s bedside table. Licensed practical nurse (LPN) #1 identified the medication as albuterol sulfate HFA (hydrofluoroalkane) 90 micrograms (mcg). There were zero puffs remaining in the inhaler. C. Record review -Review of Resident #3’s electronic medical record (EMR) failed to reveal that a self-administration evaluation assessment to keep the resident’s albuterol sulfate inhaler at the bedside was completed. Review of Resident #3’s [DATE] CPO revealed a physician’s order for albuterol sulfate HFA 90 mcg two puffs inhaled every four hours as needed for shortness of breath and wheezing, ordered [DATE]. -Resident #3’s [DATE] CPO failed to reveal a physician’s order for the resident to keep the albuterol sulfate inhaler at the bedside and self-administer the medication. -Review of Resident #3’s comprehensive care plan, initiated [DATE], failed to identify the resident was safe to keep medications at the bedside. -Resident #3’s [DATE] MAR revealed there were no self-administered doses of the albuterol sulfate documented. A Self-Medication Evaluation form, dated [DATE] (during the survey), documented Resident #3’s cognitive ability was adequate with no identified limitations to the self-administration of albuterol sulfate. D. Staff interviews LPN #1 was interviewed on [DATE] at 5:30 p.m. LPN #1 said she was aware Resident #3 had the albuterol sulfate inhaler on the bedside table. LPN #1 reviewed Resident #3’s EMR and was unable to locate a physician’s order for the resident to self-administer the medication. After confirming the self-administration evaluation assessment and form had not been completed, LPN #1 said she would notify the physician to obtain a self-administration order. The director of nursing (DON) was interviewed on [DATE] at 5:50 p.m. The DON said that all residents with medications at the bedside should be evaluated by cognitive ability to determine the clinical appropriateness of holding medications at the bedside. III. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the [DATE] CPO, diagnoses included hemiplegia (paralysis on one side of the body) affecting the right dominant side, cerebral infarction (stroke), diabetes mellitus type 2, breast cancer, and hypothyroidism. The [DATE] minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15. She was dependent on staff for all ADLs. B. Observations and resident representative interview On [DATE] at 10:02 a.m., registered nurse (RN) #1 entered Resident #8’s room. RN #1 informed Resident #8 that she was going to administer the resident’s Refresh Tears ophthalmic solution eye drops. The resident's representative indicated that they had already administered the eye drops. The eye drops were sitting on the resident’s bedside table. Resident #8’s resident representative was interviewed on [DATE] at 10:02 a.m. The resident’s representative said he administered the eye drops for Resident #8 when he believed the resident needed them. C. Record review Review of Resident #8’s [DATE] CPO revealed a physician’s order for Refresh Tears ophthalmic solution. Instill one drop in both eyes in the morning. -Resident #8’s [DATE] CPO failed to reveal a physician’s order for the resident to keep the Refresh Tears eye drops at the bedside and self-administer the medication. -Review of Resident #8’s EMR failed to reveal that a self-administration evaluation assessment to keep the resident’s Refresh Tears eye drops at the bedside was completed. -Review of Resident #8’s comprehensive care plan, initiated [DATE], failed to reveal a care plan for the self-administration of eye drops. D. Staff interview RN #1 was interviewed on [DATE] at 10:15 a.m. RN #1 reviewed Resident #8’s EMR and confirmed there was no physician's order to allow the resident’s representative to administer the medication. She said,” I will contact the physician for an order to self-administer the medication, which would allow the resident’s representative to administer the medication to the resident. IV. Resident #13 A. Resident status Resident #13, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included malignant neoplasm of the pancreas ( cancerous abnormal growth in the pancreas), malignant neoplasm of the liver (liver cancer), and intrahepatic bile duct ( cancer of the bile duct). The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15 The resident had generalized muscle weakness and needed assistance with gait and mobility (walker use) and needed assistance with personal care. B. Observations and resident interview On [DATE] at 10:00 a.m. Resident #13 had a bottle of Rolaids at the bedside. The resident was sitting up in bed watching a TV program. At 3:15 p.m. the bottle of Rolaids remained on the resident’s bedside table. Resident #13 was interviewed on [DATE] at 3:30 p.m. Resident #13 said, “I needed to take a Rolaids tablet every other day, after medication, due to acid reflux.” On [DATE] at 8:35 a.m. the same bottle of Rolaids continued to be on Resident #13’s bedside table. On [DATE] at 8:45 a.m. the bottle of Rolaids remained on Resident #13’s bedside table within reach of the resident. C. Record review -Review of Resident #13’s [DATE] CPO failed to reveal a physician’s order for Rolaids or for the resident to self-administer medications. -Review of Resident #13’s EMR failed to reveal that a self-administration assessment for medications had been completed. D. Staff interview LPN #1 was interviewed on [DATE] at 5:20 p.m. LPN #1 reviewed Resident #13’s physician’s orders and said there was no physician’s order for the resident to self-administer the Rolaids. She said there was no assessment for the resident’s self-administration of medications. LPN #1 said she would call the physician for an order and complete the assessment form for self-administration. The director of nursing (DON) was interviewed on [DATE] at 12:00 p.m. The DON said he had completed an audit (during the survey) of all residents to ensure they did not have medications in their rooms. He said assessments and physician’s orders would be obtained for the residents who were assessed to be appropriate for self-administration of medications.

Based on record review and interviews, the facility failed to provide written notice of room changes for two (#14 and #19) of five residents reviewed for notifications out of 21 sample residents.Specifically, the facility failed to ensure Resident #14 and Resident #19 received written notice of a room change. Findings include: I. Resident #14A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included aftercare following surgery on the circulatory system, type 2 diabetes with diabetic kidney complication, end stage renal disease, dissection of the ascending aorta (tear in the lining of the aorta), encephalopathy (altered brain function or structure), dysphagia (difficulty swallowing) and muscle weakness.B. Record reviewThe progress note, dated 6/5/25, revealed a message was left for the resident's son, requesting a callback. The resident's friend was contacted to discuss a room change. The resident's friend mentioned that she would also reach out to the resident's son and inform him.Review of Residents #14's electronic medical record (EMR) revealed no documentation that the resident or their representative was provided written documentation of the room change. II. Resident #19 A. Resident statusResident #19, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included displaced intertrochanteric fracture of the right femur with subsequent fracture with routine healing, subluxation of the cervical vertebrae, Alzheimer's disease, dementia, systemic inflammatory response syndrome, and abnormalities of gait/mobility. B. Record reviewThe progress note, dated 6/16/25, the note documented that the writer contacted the resident's representative to provide an update regarding a room transfer. The note documented the family preferred the resident to be placed nearer to the nurses' station while waiting for an observation room. The note documented both the son and other family members were informed of the move and assisted in relocating the resident to room [ROOM NUMBER].-However, review of Residents #19's EMR revealed no documentation that the resident or their representative was provided written documentation of the room change. III. Staff interviewsThe caseworker was interviewed on 7/23/25 at 11:30 a.m. The caseworker said the social services department did not have anything to do with the room changes. She said the nurses were responsible for notifying the family.The director of nursing (DON) was interviewed on 7/23/25 at 5:30 p.m. The DON said he reviewed the record for both Resident #14 and Resident #19 and confirmed there was information in the record for the reason for the room change and notification. He said the facility did not have a policy for resident room changes. The DON said prior to each resident's room reassignment, a written progress note or formal documentation was provided to the individual. The DON said the documentation outlined the specific rationale for the room change, such as care needs, compatibility with a new roommate, or facility logistics. The DON said the family members were notified via telephone. The DON said during these calls, the staff clearly communicated the reason for the room change and allowed for any necessary discussion.

Based on observations, record review and interviews, the facility failed to ensure services provided to residents met professional standards of quality for two (#10 and #8 ) of one resident out of 21 sample residents.Specifically, the facility failed to ensure physician's orders for pain medications included parameters for when to administer specific pain medications for Resident #10 and Resident #8.Findings include: I. Facility policy and procedure The Analgesia policy and procedure, dated 2/1/18, was provided by the nursing home administrator (NHA) on 7/23/25 at 12:24 p.m. The policy read in pertinent part, “Nurses must follow pain parameters and enter pain scales for pain medicines. If a resident wants one pain pill and they rate their pain 7-10 and the order reads to give two for pain of 6-10, it must be charted that it was per resident request. Nurse management must be notified so it can be care planned.” II. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included nondisplaced fracture of left radial styloid process (bony projection located on the thumb side of the wrist), hypertension (high blood pressure) and type 2 diabetes. The Nursing Comprehensive admission Data assessment, dated 7/9/25, revealed the resident was alert and oriented to person, place, time and situation. She required setup and clean-up assistance for eating and substantial/maximal assistance for transfers and toileting. B. Record review Review of Resident #10’s July 2025 CPO revealed the following physician’s orders for as needed (PRN) pain medications: Oxycodone HCL oral tablet five milligrams (mg), give one tablet by mouth every eight hours as needed for pain, ordered 7/9/25. Acetaminophen oral tablet, give 650 mg by mouth every four hours as needed for pain, ordered 7/9/25. Record review of the MAR shows Resident #10 received oxycodone for four out of ten pain on 7/9/25 and 7/10/25 when the resident could have received acetaminophen prior to giving an opioid pain medication. -Review of the physician’s orders for Resident #10’s pain medications failed to include pain level parameters for when to administer each specific pain medication or which pain medication to administer based on the resident’s pain level. C. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 7/23/25 at approximately 10:15 a.m. LPN #2 said Resident #10 had pain in her arm due to a fractured wrist. LPN #2 said Resident #10 had both acetaminophen and oxycodone for PRN pain medications. LPN #2 said the nurses used their prior education, nursing judgement and the resident’s pain rating to decide whether to give Resident #10 acetaminophen or oxycodone. LPN #2 said that in general, any physician’s order that was more specific could be more helpful. D. Facility follow-up On 7/23/25, during the survey, Resident #10’s physician’s order for oxycodone HCL was changed to read oxycodone HCL oral tablet five mg, give one tablet by mouth every eight hours as needed for pain level of 6-10 out of 10. III. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 CPO, diagnoses included hemiplegia (paralysis on one side of the body) affecting the right dominant side, cerebral infarction (stroke), diabetes mellitus type 2, breast cancer, and hypothyroidism. The 5/21/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of zero out of 15. She was dependent on staff for all activities of daily living (ADL). B. Record review Review of Resident #8’s July 2025 CPO revealed the following physician’s orders for PRN pain medications: Morphine sulfate (concentrate) oral solution 100 mg/5 milliliters (ml). Give 0.5 ml via PEG-Tube (percutaneous endoscopic gastrostomy tube - a feeding tube inserted through the abdominal wall into the stomach) every four hours as needed for pain of 1-10 out of 10, ordered 5/12/25. -Oxycodone HCl oral tablet 5 mg. Give one tablet by mouth every six hours as needed for pain of 1-10 out of 10, ordered 5/7/25. -Review of the physician’s orders for Resident #8’s pain medications failed to include pain level parameters for when to administer each specific pain medication or which pain medication to administer based on the resident’s pain level. Review of Resident #8’s July 2025 medication administration record (MAR) revealed morphine was administered on the following dates: -7/7/25 for a pain level of 5; and, –7/7/25 for a pain level of 7. Review of Resident #8’s July 2025 MAR revealed oxycodone was administered on the following dates: -7/12/25 for a pain level of 5; -7/13/25 for a pain level of 5; -7/18/25 for a pain level of 7; and, -7/22/25 for a pain level of 5. C. Staff interview The director of nursing (DON) was interviewed on 7/23/25 at 3:54 p.m. The DON said all physician’s orders were to be followed. He said Resident #8 was nonverbal. He reviewed the resident’s medical record and confirmed that the morphine and the oxycodone did not have specific pain parameters. The DON said the nurse manager reviewed the physician’s orders to ensure they were entered into the residents’ medical records properly with pain parameters. However, he said the floor nurses did not consistently add pain parameters to medications when they entered physician’s orders for pain medications.

Based on observations, record review, and interviews, the facility failed to provide adequate supervision during the use of assistive devices to keep residents free from safety hazards for three (#20, #21, and #5) of the six residents out of 21 sample residents. Specifically, the facility failed to ensure Resident #20, Resident #21, and Resident #5's foot pedals were in place on their wheelchairs when staff were transporting the residents.Findings include: I. Resident #20 A. Resident status Resident #20, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, history of falls, difficulty walking, muscle weakness, and a need for assistance with personal care. The 7/10/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required assistance with personal hygiene. The MDS assessment revealed the resident had a history of falls. B. Observations and resident interview On 7/22/25 at 2:20 p.m., Resident #20 was being pushed in her wheelchair by a front office staff member without foot pedals attached to her wheelchair. C. Record review Review of Resident #20’s fall care plan, initiated on 7/10/25, identified the resident as high risk for falls. Interventions included physical therapy and occupational therapy. -The care plan did not include an intervention to ensure that Resident #20’s foot pedals were in place when transporting the resident in the wheelchair to prevent potential falls. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted on [DATE]. According to the July 2025 CPO, diagnoses included fracture of the right femur and muscle weakness. The 7/5/25 MDS assessment revealed that Resident #21 had moderate cognitive impairment with a BIMS score of eight out of 15. The resident needed set up with eating and needed moderate assistance transferring. The MDS assessment revealed that Resident #21 was a high fall risk and had a fall in the month prior to admission. B. Observations On 7/22/25 at 12:10 p.m. an unidentified certified nurse aide (CNA) was observed pushing Resident #21 to her room in her wheelchair. There were no foot pedals attached to the wheelchair. On 7/22/25 at 12:47 p.m. Resident #21 was transported in her wheelchair away from the table by an unidentified CNA. There were no foot pedals attached to the wheelchair and the resident’s feet were dangling. On 7/22/25 at 2:32 p.m. Resident #21 was being pushed in her wheelchair by an unidentified CNA. The resident did not have foot pedals on her wheelchair and her feet were dangling as she was being pushed. On 7/22/25 at 4:45 p.m. Resident #21 was again being pushed in her wheelchair by an unidentified CNA. There were no foot pedals on her wheelchair and the resident’s feet were dangling. III. Resident #5 A. Resident status Resident #5, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included dementia, Alzheimer’s disease and history of falling. The 5/30/25 MDS assessment revealed the resident had both short term and long term memory impairments. The resident was severely cognitively impaired with a BIMS score of zero out of 15. The resident was dependent on staff for ADLs. B. Observations On 7/21/25 at 5:05 p.m. Resident #5 was sitting in her wheelchair in her room. There were no foot pedals attached to the wheelchair, causing the resident’s feet to dangle. On 7/22/25 at 11:25 a.m. Resident #5 was sitting in her wheelchair near the nurses’ station. There were no foot pedals attached to the wheelchair, which caused the resident’s feet to dangle. On 7/22/25 at 12:02 p.m. Resident #5 was being pushed through the hallway in her wheelchair by an unidentified staff member. There were no foot pedals attached to the wheelchair, which caused the resident to drag her feet across the floor. Other staff members were in the vicinity; however, no staff members intervened. C. Record review The fall care plan, initiated 8/29/24, identified Resident #5 as a high fall risk and identified interventions to prevent potential falls. -However, the care plan failed to include an intervention to ensure Resident #5’s foot pedals were in place when transporting the resident in her wheelchair in order to prevent potential falls. The fall risk assessment, dated 8/30/24, revealed Resident #5 was a high fall risk. -The 3/17/25 fall intervention and prevention checklist failed to include an intervention to ensure Resident #5’s foot pedals were in place when transporting the resident in her wheelchair in order to prevent potential falls. IV. Staff interviews The director of nursing (DON) was interviewed on 7/23/25 at 12:05 p.m. The DON said when residents were pushed in their wheelchairs, they needed to have foot pedals on their wheelchairs for safety. The DON said staff should always be using foot pedals when pushing residents. The director of rehabilitation (DOR) was interviewed on 7/23/25 at 3:30 p.m. The DOR said that while working with therapy, removing the wheelchair pedals could benefit the residents by allowing them to build and maintain muscle strength. He said the residents’ feet should not dangle from the wheelchair or drag across the floor when staff were transporting the resident due to the risk of gravity taking over and causing the resident to fall forward out of the wheelchair. The DON was interviewed a second time on 7/23/25 at 4:45 p.m. The DON said he had started education with the staff on the importance of ensuring foot pedals were on wheelchairs when transporting residents.

Based on observations, record review, and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for two (#8 and #3) of the four residents reviewed with a feeding tube out of 23 sample residents.Specifically, the facility failed to ensure:-Resident #8's physician's orders were complete and accurate, with the correct route, and orders were followed; and,-Resident #3 received adequate hydration per the registered dietitian's (RD) recommendations. Findings include: I. Facility policy and procedure The Administering Medications Through an Enteral Tube policy, revised on 3/19/24, was provided by the nursing home administrator (NHA) on 7/23/25 at 9:44 a.m. It read in pertinent part, “If at any time the patient cannot tolerate the feeding, place the feeding on hold and notify the provider. “Tablets that must be crushed before administration through an enteral tube require a specific order related to crushing. “When the last of the medication begins to drain from the tubing, flush the tubing with 15 ml (milliliter) of warm sterile or purified water (or prescribed amount).” II. Resident #8 A. Resident status Resident #8, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician’s orders (CPO), diagnoses included hemiplegia (paralysis on one side of the body) affecting the right dominant side, cerebral infarction (stroke), diabetes mellitus type 2, breast cancer, and hypothyroidism (decreased function of the thyroid). The 5/21/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview for mental status (BIMS) score of zero out of 15. The resident was experiencing coughing and choking during medication administration and meals, which increases the resident's risk for aspiration. She was dependent on staff for all activities of daily living. The resident has a percutaneous endoscopic gastrostomy (PEG) tube. B. Observations On 7/21/25, at 4:40 p.m. Resident #8 was receiving a scheduled tube feeding. The tube feeding pump indicated the formula was running at 50 ml/hr, with 150 ml of water flush every four hours. On 7/23/25 at 9:25 a.m., registered nurse (RN) #1 was administering Resident #8’s medication via her peg tube. She administered the medications by syringe push. C. Resident #8’s representatives interview Resident #8’s representative was interviewed on 7/22/25 at p.m. The resident’s representative said Resident #8 had a swallow study, 5/25/25, and she continued to be at risk for aspiration. She said it was recommended for the resident’s PEG tube to remain permanent at this time. D. Record review Review of the July 2025 CPO revealed the following physician’s orders related to Resident #8’s percutaneous endoscopic gastrostomy (PEG) tube: Nothing by mouth (NPO), ordered 3/21/25; Enteral feed order every shift for tube feeding, 30ml flush before and after medications, ordered 1/31/25; Glucerna 1.5-calorie oral liquid (nutritional supplements). Give 50 ml per hour (ml/hr) by mouth two times a day for nutrition for 18 hours, off for six hours daily with 150 ml water flushes every four hours, ordered 7/15/25; Furosemide oral tablet (water pill). Give 20 milligrams (mg) by mouth in the morning for fluid volume overload, ordered 5/21/25; and, Guaifenesin oral tablet 400 mg. Give one tablet by mouth three times a day for congestion, ordered 7/9/25 . -The physician’s orders indicated to give the furosemide and Guaifenesin orally. However, Resident #8 was NPO. The nutrition assessment, dated 2/4/25, documented the resident had lost 9.4 pounds (lbs) in 30 days. The tube feeding regime was changed and the resident then gained 10 lbs. The feedings were adjusted. The assessment documented the resident's weight was 152.2 lbs on 2/3/25. E. Staff interviews The director of nursing (DON) was interviewed on 7/23/25 at 11:20 am. The DON said she reviewed the physician’s orders for Resident #8. The DON said some of the physician’s orders were not accurate and indicated for the licensed nurses to administer medications orally. The DON said all of the resident’s medications needed to be administered via the PEG tube. She said she would review the resident’s physician’s orders and ensure the orders were accurate as to what route the medication needs to be administered. The DON said the nurse who entered the physician’s orders into the electronic system was responsible to ensure the orders were complete and accurate. The RD was interviewed on 7/23/25 at 12:42 p.m. The RD said the resident was nothing by mouth as she had a peg tube. He said that he assesses the resident and then puts in a recommendation for the formula and the rate. He said that he then provides it to the nurses who then contact the physician. He said the nurses were responsible for putting the orders in and ensuring it was written correctly. F. Facility follow-up On 7/23/25 at 3:00 p.m. (during the survey), the DON provided documentation indicated the physician’s orders for Resident #8 were updated with the correct route of administration. III. Resident #3 A. Resident status Resident #3, age greater than 65, was admitted on [DATE]. According to the July 2025 CPO, diagnoses included chronic obstructive pulmonary disease (air flow blockage), acute and chronic respiratory failure (decrease in the ability to bring oxygen into the bloodstream) and dysphagia. According to the nursing comprehensive admission data collection, dated 7/18/25, the resident was alert and oriented to person, place, time and situation, requiring supervision for activities of daily living. B. Resident interview Resident #3 was interviewed on 7/21/25 at 5:20 p.m. Resident #3 said she was experiencing nausea and had refused her tube feedings. She said the nurses administered feedings and medications by gravity feeds. Resident #3 was interviewed again on 7/22/25 at 11:15 a.m. Resident #3 complained of increased nausea. She said the nausea was a new symptom, and she was unsure what caused it. C. Observations On 7/22/25 at 3:55 p.m. LPN #1 was administering an oxycodone-acetaminophen (pain medication) tablet and a water flush through Resident #3’s feeding tube per the resident’s request. The medication was administered by gravity. -LPN #1 did not measure the water flush. LPN #1 administered an unidentified amount of water into Resident #3’s feeding tube before and after she administered the oxycodone-acetaminophen tablet (see interview below). D. Record review Review of the July 2025 CPO revealed the following physician’s orders related to Resident 3’s PEG tube: Isosource 1.5 cal (enteral nutritional supplement) 250 ml to be administered four times a day. Give 100 ml water flush before and after each feed, ordered 7/17/25. Give 60 ml water flush four times a day to provide an additional 240 ml of hydration each day, ordered 7/17/25. -Review of the July 2025 medication administration record (MAR) did not reveal documentation indicating Resident #3 was administered 60 ml of water four times a day per physician's orders. Review of Resident #3’s electronic medical record (EMR) revealed the physician’s orders failed to specify the amount of water that should be administered during the medication administration process. Review of Resident #3’s EMR revealed LPN #1 documented that she administered 100 ml of water following the medication administration of oxycodone-acetaminophen. Resident #3’s nutrition assessment, dated 7/20/25, revealed the registered dietitian (RD) documented the current enteral nutrition physician’s orders did not meet Resident #3’s estimated fluid needs based on his assessment. The RD documented the resident said she got dehydrated and had headaches. The RD recommended to increase the water flush from 100 ml to 150 ml before and after each feed administration to meet Resident #3’s hydration needs. -However, review of the July 2025 CPO did not reveal the physician's order was updated to direct staff to administer 150 ml of water before and after each feed as recommended by the RD. E. Staff interviews LPN #1 was interviewed on 7/22/25 at 3:55 p.m. LPN #1 said when she was administering an enteral feed for Resident #3, she administered 100 ml of the water flush before and after the feed administration per physician's orders LPN #1 said she would likely hold Resident #3’s 4:00 p.m. tube feeding as a result of the resident’s continued symptoms of nausea and constipation. She said she decided to administer 100 ml of the water flush during the administration of the oxycodone-acetaminophen tablet. The RD was interviewed on 7/23/25 at 12:55 p.m. He said he completed a nutritional assessment for each resident upon admission. He said when he thought it was necessary to change an enteral feed formula, he completed a new assessment. He said through the assessment he reevaluated the resident’s nutritional needs. He said he then compared the resident’s nutritional needs to the nutritional value the current physician's order was providing. The RD said he was unable to enter nutritional orders into the residents’ EMR. He said the physician wrote the orders.

Based on observations, record review and interviews, the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#30 and #5) of six residents reviewed for falls out of 28 sample residents. Resident #30, who was severely cognitively impaired and had a history of falls, was admitted to the facility on [DATE] after a fall at home which resulted in a left hip fracture requiring surgical repair. Upon the resident's admission, the facility initiated a fall care plan with generalized interventions that were implemented for all residents, including an intervention to ensure the resident's call light was within reach and a Call, don't fall sign was to be posted in the resident's room. -However, the facility failed to appropriately assess Resident #30's ability to use her call light and understand what the Call, don't fall sign was for due to her severe cognitive impairments. The facility did not implement person-centered fall interventions that were specific to Resident #30 and staff were not educated regarding the resident's increased need for supervision to prevent falls. On 7/26/24, Resident #30 sustained a fall from bed without injury. The immediate interventions were to remind the resident to use her call light, despite the fact the resident had severe cognitive impairments and frequent checks by staff for safety. On 8/1/24, Resident #30 sustained a second fall, this time in her bathroom. The resident complained of increased left hip pain and was transferred to the hospital where it was discovered the resident had refractured her left hip, requiring a second surgical repair. Due to the facility's failures to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased need for supervision, Resident #30 sustained two falls within 13 days of being admitted to the facility, with the second fall resulting in a major injury. Additionally, for Resident #5, the facility failed to implement timely person-centered fall interventions and ensure staff were aware of the resident's increased risk for falls due to Parkinson's disease. Between 7/9/24, the date the resident admitted to the facility, and 8/15/24, Resident #5 sustained seven falls. Two of the falls occurred on 8/15/24 within one hour and 15 minutes of each other. Findings include: I. Facility policy and procedure The Fall Prevention policy, revised July 2023, was provided by the nursing home administrator (NHA) on 8/28/24 at 1:05 p.m. It read in pertinent part, Falls in the skilled nursing setting represent one of the most potentially devastating occurrences that can negatively impact a resident's recovery. In facilities, falls directly cause tens of thousands of bone fractures, intracranial hemorrhages, re-hospitalization s, and deaths every year in the United States. It is because of these unfortunate events that the facility is implementing its comprehensive program to prevent falls and injury. Procedure: Any resident deemed to be high risk by nursing and/or therapy staff will have the following interventions at least considered: -Thorough physical and occupational therapy evaluation; -Low bed (or lower standard bed to its lowest position); -Routine toileting schedule throughout shift; -Line of sight as needed; -Nursing staff as needed; -Consult pharmacist to review medications as needed; -Encourage resident to participate in monitored activities; and, -Move the resident to a room closer to the nurse's station. Dementia or altered mental status, not oriented: -Admit in a room closest to the nurses' station or observation room if available; -Routine toileting schedule throughout the shift; -Residents not to be left alone in the bathroom; and, -Round on residents throughout the shift. Post fall procedure: -Determine what interventions need to be implemented to prevent further falls; and, -Complete orders and/or tasks for fall prevention. II. Resident #30 A. Resident status Resident #30, age 88, was admitted on [DATE] and readmitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, other mechanical complication of internal fixation device of left femur, subsequent encounter, mild cognitive impairment, type 2 diabetes mellitus with hyperglycemia, muscle weakness, unspecified dementia and periprosthetic fracture (broken bone that occurs around an orthopedic implant) around internal prosthetic left hip joint. The 7/25/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. She required substantial/maximum assistance with toileting, bathing, and partial/moderate assistance with transfers. B. Resident observation and staff interview Resident #30 was observed on 8/26/24 at 12:40 p.m. in the nurses' station area. She was sitting in a wheelchair with her eyes closed. Registered nurse (RN) #1 said Resident #30 fell a few weeks ago (8/1/24) and refractured her left hip. She said on readmission, the resident was placed in the observation room close to the nurses' station for safety. RN #1 said the resident could not use the call light. She said the staff frequently brought Resident #30 to the nurses' station to keep an eye on her. She said Resident #30 had not made any physical progress since her readmission, had quit eating food and would be discharged to a hospice care facility. C. Record review Resident #30's activities of daily living (ADL) care plan, initiated 7/19/24, revealed the resident had an actual/potential decline in her ability to perform her ADLs due to impaired mobility related to a left hip fracture with surgical repair. Interventions included encouraging the resident to do as much as possible for herself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The transfers/toileting care plan, initiated 7/19/24, revealed the resident required assistance with transfer/toileting related to impaired mobility secondary to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance. -The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/19/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, a fall with a left hip fracture prior to admission, cognitive impairment and the resident's current drug regimen. Interventions included keeping the call light within reach, reinforcing the need to call for assistance and wearing proper non-slip footwear. -However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The high risk faller care plan, initiated 7/19/24, revealed the resident was at high risk for falls but was aware she might have a fall with major injury. Interventions included placing a Call, don't fall sign in the resident's room to remind the resident to call for assistance and having adequate lighting. -However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. The actual fall care plan, initiated 7/26/24, revealed Resident #30 was at risk for further falls related to attempting to self transfer without calling for assistance, functional/clinical decline, impulsivity and poor safety awareness. Interventions included placing a Call, don't fall sign in the resident's room to remind the resident to call for assistance and rounding on the resident throughout the shift. -However, Resident #30 had severe cognitive impairments and her ability to remember to use the call light or call for assistance was impaired. -The care plan did not indicate how often the resident should be rounded on during the shift. -None of the above care plans were updated with additional fall interventions upon Resident #30's readmission to the facility following her fall with major injury, hospitalization and surgical repair of her refractured left hip. 1. Fall #1 A nurse progress note dated 7/26/24 documented the resident was found on the floor by certified nurse aide (CNA) at 6:30 a.m. When the nurse entered the resident's room, the resident was sitting on the floor near the bed. The resident was confused and said she tried to get up from the bed and slid on the floor but did not hit her head. The resident was assessed, able to move both hands and her right leg. She was not able to move her left leg due to her recent left hip repair. No injuries were noted. The resident was educated and reminded to use her call light for all transfers and needs. Frequent checks by staff for safety were implemented and the resident was assisted back to bed by two staff members with the use of a gait belt. The family and the physician were notified and an order for an x-ray was obtained as a precaution. A post fall evaluation dated 7/26/24 documented the probable cause of the fall was the resident did not use her call light and tried to get out of bed by herself. The resident was confused. -However, the intervention after the fall, despite the resident's cognitive impairments and confusion, was to remind the resident to use the call light. The interdisciplinary team's (IDT) review of the 7/26/24 fall documented the resident had no change in her level of consciousness or orientation status. The provider ordered bilateral hip x-rays after the fall, which her negative for any new fractures. The resident was verbally educated on call light use and verbalized verbalized understanding. Current fall interventions included a Call, don't fall sign. A new intervention for frequent checks was initiated and the resident would continue to work with therapy on balance and strength training. A physician's note dated 7/29/24 documented Resident #30's cognitive impairment was likely consistent with at least mild dementia. The resident did not have agitation but the resident was unable to provide much meaningful information and seemed to be repetitive. A social services note dated 7/30/24 documented Resident #30 was drowsy and unable to stay awake long enough to discuss the Notice of Medicare Non-coverage (NOMNC). The resident was only able to score a two out of 15 on BIMS assessment. -However, despite the resident's cognitive impairments and confusion, the facility continued to utilize reminding the resident to use the call light as a fall intervention. 2. Fall #2 A nurse progress note dated 8/1/24 documented a RN was called to the resident's room for a reported fall. The resident was found on the floor in the bathroom, diagonally between the shower and the toilet. The resident was complaining to her post-surgical left hip. The RN assessed the resident and the surgical site was reasonably intact, however, there was suspicion the resident re-injured or refractured her left hip. The physician was notified and a physician's order was obtained to send the resident to the hospital for further assessment and treatment. The resident's family was notified. A post fall evaluation dated 8/1/24 documented the probable cause of fall was the resident's non-compliance with call light use, self-ambulating without assistance from staff and poor safety awareness. The IDT's review of the 8/1/24 fall documented the resident had no change in her level of consciousness or orientation status. Current fall interventions included a Call, don't fall sign. The resident was sent to the hospital due to concerns for re-injury to her left hip. Per the 8/1/24 hospital left hip x-ray (see hospital record below), worsening of the left hip fracture was noted. The resident was admitted to the hospital. The resident would be admitted into an observation room upon her readmission to the facility. A hospital progress note dated 8/1/24 documented the resident was a very pleasant female who sustained a ground level fall and was brought to the emergency department with a periprosthetic femur fracture. She had undergone cephalomedullary nailing of a left intertrochanteric femur fracture about two and half weeks prior. On 8/1/24 she was in a rehabilitation facility and sustained an unwitnessed fall. Upon presentation to the emergency department, she was noted to have a periprosthetic femur fracture around the short cephalomedullary nail that had been placed. The injury was discussed with the resident's legal representative regarding the diagnosis and treatment alternatives, including the risks of surgery. The resident's representative expressed understanding of the risks and desired to proceed with surgery. Resident #30 readmitted to the facility on [DATE] and was admitted into an observation room close to the nurses station (see interviews below). A social services note dated 8/14/24 documented the social worker spoke with the resident and family during a care conference. The discussion included information about hospice care and needs for next level care at home. The family was provided pamphlets about hospice services, Medicaid assistance and caregiving services. A nurse progress note dated 8/26/24 (during the survey) documented Resident #30 was discharged at 2:25 p.m. to another facility with hospice care services. D. Staff interview The director of rehabilitation (DOR) was interviewed on 8/29/24 at 10:45 a.m. The DOR said Resident #30 was initially admitted on the third floor, however, after two falls and the hospitalization , she was readmitted to the observation room close to the nurses station on the second floor on 8/3/24. He said he was not aware Resident #30 could not use a call light. III. Resident #5 A. Resident status Resident #5, age 69, was admitted on [DATE]. According to the August 2024 CPO, diagnoses included acute cystitis (inflammation of the bladder) with hematuria (blood in the urine), Parkinson's disease, insomnia, benign prostatic hyperplasia (noncancerous enlargement of the prostate gland) with lower urinary tract symptoms, type 2 diabetes mellitus, overactive bladder, unspecified mood disorder, history of transient ischemic attack (TIA) and cerebral infarction (stoke) and the presence of a neurostimulator (a device that uses electrical stimulation to treat neurological and psychiatric disorders). The 7/13/24 MDS assessment revealed the resident's cognition was intact with a BIMS score 14 out of 15. The resident did not have rejection of care and no behaviors were noted. The resident's range of motion of upper and lower extremity was impaired on both sides. He was dependent on staff with toileting and required substantial/maximal assistance with all transfers (bed/wheelchair/toilet). B. Resident and family interview Resident #5 and his wife were interviewed together on 8/26/24 at 2:30 p.m. Resident #5 said he was not aware how to use the call light for the first few days in the facility and he did not realize he was not strong enough to transfer himself from his bed to his wheelchair. Resident #5's family member said, with his Parkinson's diagnosis, Resident #5 was falling frequently at home when she was at work and the facility was aware of the resident's poor safety awareness upon his admission to the facility. She said Resident #5 had previously sustained traumatic brain injuries and he did not realize he needed assistance with transfers. C. Record review Resident #5's ADL care plan, initiated 7/9/24, revealed the resident had actual/potential decline in his ability to perform his ADLs due to impaired mobility related to Parkinson's disease. Interventions included encouraging the resident to do as much as possible for himself as able, placing the call light within reach and providing assistance as needed with grooming, bathing and personal hygiene and per the resident's preferences. The bowel incontinence care plan, initiated 7/9/24, revealed the resident was incontinent of bowel due to impaired mobility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance. -The care plan did not indicate how often the resident should be checked on. The transfers/toileting care plan, initiated 7/9/24, revealed the resident required assistance with transfer/toileting related to weakness and debility. Interventions included checking on the resident frequently and assisting with toileting as needed, keeping the call light within reach and reminding the resident to call for assistance. -The care plan did not indicate how often the resident should be checked on. The fall care plan, initiated 7/9/24, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility, Parkinson's disease, history of falls, neuropathy (a nerve disease or damage that can cause pain, numbness, or tingling in different parts of the body) and the resident's current drug regimen. Interventions included keeping the call light within reach, keeping commonly used items within reach, occupational therapy (OT) and physical therapy (PT) to evaluate and treat as needed. The actual fall care plan, initiated 7/25/24, revealed the resident had a fall at the facility and was at risk for further falls related to attempting to transfer without assistance, confusion, functional/clinical decline, impulsivity and poor safety awareness. Interventions initiated on 7/25/24 included placing a Call, don't fall sign in the resident's room to remind the resident to call for assistance, utilizing the 4 P's, including asking does the resident need to use the bathroom, does the resident need to be repositioned, are all commonly used belongings within reach of the resident, and is the resident having pain and notifying the nurse immediately if the answer to pain was yes. Interventions initiated 8/16/24 (after seven falls - see falls below) included the use of a fall mat, keeping the bed in a low position while the resident was in bed, keeping the call light within reach at all times, using a motion sensor, moving the resident closer to the nurses station, rounding on the resident throughout the shift and providing a soft touch call light. -The care plan did not indicate how often the resident should be rounded on throughout the shift. -Despite Resident #5's intact cognition BIMS score of 14 out of 15, the facility failed to appropriately assess Resident #5's ability to use his call light for assistance based on his history of traumatic brain injuries (see family interview above). The 7/9/24 Comprehensive Nursing Assessment revealed Resident #5's fall risk score was 40, which indicated he was a moderate risk for falls. 1. Fall #1 A nurse progress note dated 7/24/24 at 3:50 a.m. documented a RN was called to Resident #5's room for a reported fall by the CNA. The resident was found lying on the floor parallel to his bed on his right side. The resident was alert with clear and discernible speech and no changes in mentation were noted. No injuries noted. The resident had little to no stated or observable pain. When asked what he was doing the resident said he fell out of bed but he did not know why he was trying to get out of bed. Staff was able to transfer the resident, once assessed, back to his bed. He was reassessed and no injuries were noted. Vital signs and neurological checks were started per protocol. The physician and family were notified. A post fall evaluation dated 7/24/24 documented the probable cause of the fall was the resident had very poor safety awareness with short term memory loss. -However, despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. The IDT's review of the 7/24/24 fall documented the resident had no change in his level of consciousness or orientation status. The resident obtained no injuries from the fall. Current fall interventions included a Call don't fall sign. New interventions initiated included the Fall Program and frequent rounding. The resident was verbally educated on the importance of call light use and the resident verbalized understanding. The resident would continue to work with therapy on balance and strength training. -Despite the resident's poor safety awareness and short term memory loss, the facility continued to utilize reminding the resident to use the call light and call for assistance as a fall intervention. 2. Fall #2 A nurse progress note dated 7/28/24 documented Resident #5 had an unwitnessed fall at 12:00 a.m. after staff did rounds on him at 11:45 p.m. He was found by staff on the left side of his bed sitting on his legs and left foot with his knees bent. The resident had a superficial scratch on his left knee and his catheter had been pulled out of the securing device attached on his left leg. The resident reported he was trying to turn off his television (TV). The RN evaluated the resident and CNAs and the RN transferred the resident back to bed. Neurological checks were initiated. -A Post Fall Evaluation dated 7/28/24 failed to document the probable cause of the fall. The IDT's review of the 7/28/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. The resident would continue to work with therapy on strength training and balance. 3. Fall #3 A nurse progress note dated 7/30/24 at 11:49 p.m. documented a RN was called to the resident's room with a suspected fall. The resident was found on the floor on his left side facing the bed, holding the bed tightly by the footboard handles, with a big grin on his face and saying he needed help. When asked, the resident stated he was needing help,and that's why he thought he might be on the floor. The resident was assessed, no injuries were noted and the resident was able to answer all inquiries per his baseline mentation. The resident returned to his bed and was reassessed with no injuries found, however, he needed to be changed which was what possibly perpetuated the fall. The physician and family were notified. Vital signs and neurological checks were restarted per protocol. -A post fall evaluation dated 7/30/24 failed to document the probable cause of the fall. The IDT's review of the 7/30/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. The facility planned to move the resident to an observation room once one was available. A medication review was completed on the resident by the physician and new orders were obtained to discontinue the resident's scheduled Ambien. The resident would continue to work with therapy on strength training and balance. 4. Fall #4 A nurse progress note dated 8/6/24 at 6:24 a.m. documented the RN was called to the resident's room and no injuries were noted. The resident was assessed and returned to bed. Vital signs and neurological checks were started per protocol. The physician and family were notified. -A post fall evaluation dated 8/6/24 failed to document the probable cause of the fall. The IDT's review of the 8/6/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a Call don't fall sign, frequent rounding and the 4 P's. The resident remained on the fall program. A new intervention was implemented for a motion sensor at night. The resident would continue to work with therapy on strength training and balance. -However, staff was not aware the motion sensor needed to be turned on when the resident went to bed at night (see interviews below). 5. Fall #5 A nurse progress noted dated 8/13/24 at 2:15 p.m. documented the nurse responded to Resident #5's fall and immediately placed a pillow underneath the resident's head for comfort. Neurological checks were within normal limits and the resident denied a headache, nausea or vomiting or vision changes. There was no immediate bruising or redness noted to any areas assessed. The resident's range of motion was intact as prior to the fall and there was no lengthening or shortening of his upper or lower extremities noted. The resident's speech was soft, but clear and understood. The resident was transferred to his wheelchair with the assistance of two staff members and a gait belt and tolerated it well. The resident was taken to the nurses' station/common area for one-to-one supervision. -The facility failed to document a Post Fall Evaluation or IDT review for the fall. -The progress note failed to document any new fall interventions put into place following the fall. 6. Fall #6 A nurse progress note dated 8/15/24 at 9:20 p.m. documented a CNA notified the nurse about the resident lying on the floor lying on his back. He was alert and oriented to person and place. The resident stated he crawled from his bed, kneeled down to the floor and continued to crawl out to the door. He said he did not fall but wanted to get out of his room. The resident said he did not hit his head. His range of motion was within normal limits and he denied pain. The resident was able to follow all commands. He was assisted to sit in his chair and able to bear weight on both of his legs/feet. Neurological checks and monitoring were initiated. -The facility failed to document a post fall evaluation or IDT review for the fall. -The progress note failed to document any new fall interventions put into place following the fall. 7. Fall #7 A nurse progress note dated 8/15/24 at 10:35 p.m. documented the resident's spouse was visiting and informed the nurse the resident was on the floor. The nurse found the resident crawling on his hands and knees in the doorway. There were no injuries noted. The fall was unwitnessed. The resident stated that he rolled onto his side and crawled onto the floor. The resident became a little upset when asked if he hit his head. He stated he did not hit his head. A RN assessed the resident and the resident was placed in his wheelchair after the assessment. The resident's spouse and the physician were notified. Neurological checks were initiated and the resident would continue to be monitored. -The progress note failed to document any new fall interventions put into place following the fall. -The facility failed to document a post fall evaluation for the fall. The IDT's review of the 8/15/24 fall documented the resident obtained no injuries from the fall and had no change in his level of consciousness or orientation status. The resident was verbally re-educated on safety and call light use. Current interventions included a Call don't fall sign, frequent rounding the 4 P's, a motion sensor and the resident was in an observation room. The resident remained on the fall program and the resident's wife was often at the resident's bedside. Activities would continue to offer more one-to-one activities with the resident. A request was made for a soft touch call light and a fall mat was added for resident safety due to the resident's frequent falls. The resident would continue to work with therapy on strength training and balance. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 8/27/24 at 8:20 p.m. LPN #2 said he was not aware of any specific interventions for Resident #5 for falls prevention. He said the staff usually did rounds to check on all residents. He did not specify how frequent the rounds were. CNA #3 was interviewed on 8/27/24 at 8:24 p.m. CNA #3 said he was not aware Resident #5 was at risk for falls and had already had several falls while in the facility. He said he usually did rounds when he was not busy with residents' care, however, he said there was no specific time frame to do frequent rounds. He said he was not aware there was a motion sensor in the resident's room that needed to be turned on when the resident was in bed for the night. The DOR was interviewed on 8/29/24 at 10:13 a.m. The DOR said Resident #5 required moderate assistance with transfers and short distance walks with his front-wheeled walker. The DOR said falls were discussed in morning meetings. He said Resident #5 was moved to the observation room on the second floor by the nurses station from the third floor after a couple of falls. He said the resident's falls were related to his poor cognition. He said the resident was unable to maintain not any safety education. The DOR said therapy focused on transfer training and safety and routine with the resident, but he worried about injury prevention. He said the therapy staff was working on fall recovery techniques with the resident. LPN #1 was interviewed on 8/29/24 at 10:0 a.m. LPN #1 said he was not aware of any specific fall prevention approaches for Resident #5, except frequent checks and call light within reach. He said there was no set time frame for frequent checks, it could be once every hour. IV. Director of nursing (DON) interview The DON was interviewed on 8/29/23 at 10:45 a.m. The DON said when a resident was accepted for admission, the admission coordinator screened for fall risk and notified the floor nurse to initiate fall prevention interventions. The DON said the 4 P's were the facility's fall prevention program, and every resident was at risk for falling. The DON said the admissions coordinator needed clinical credentials and he was unaware of how the admissions coordinator determined a resident's fall risk. The DON said a baseline care plan was developed for every resident at admission. The DON said the care plan was updated when a resident had a fall or required additional interventions. The DON reviewed the baseline care plans for Resident #30 and Resident #5 and said the interventions were the same because all residents were at risk for falls. He said the facility did not need to identify levels of fall risk because every resident was a fall risk, and the 4 Ps were used to prevent falls. The DON said CNAs should be aware of every resident at risk for falling by reviewing Resident task lists. He said CNAs were prompted for each resident when a resident had a fall, the care plan was updated, and CNAs were notified when they reviewed their assigned task list. -However, staff interviews revealed staff were not aware of which residents were fall risks and what fall interventions were in place for specific residents (see interviews above).

Based on observations, record review and interviews, the facility failed to provide effective pain management in accordance with professional standards for one (#1) of one resident out of 27 sample residents. Resident #1 was admitted on [DATE] with a diagnosis of intracerebral hemorrhage (stroke), type 2 diabetes, muscle weakness and adult failure to thrive. According to the 7/31/24 nursing comprehensive admission assessment for skin, Resident #1 had no skin issues. He often refused repositioning and to get out of bed due to pain. On 8/12/24 he developed pressure ulcers on his buttocks and coccyx. Additional medication was not ordered for wound care and all he was receiving for pain was Tylenol four times per day and a Lidocaine patch. On 8/27/24 Resident #1 was observed to be in severe pain during wound care of his buttocks and coccyx wounds. The facility's failure to provide effective pain management contributed to the resident suffering prolonged pain from his wounds and other areas on his body. Findings include: I. Facility policy and procedure The Pain Management policy and procedure, revised 2/8/21, was provided by the nursing home administrator (NHA) on 8/29/24 at 12:59 p.m. The policy read in pertinent part, Frequently, patients arrive from the hospital with acute pain secondary to being transferred to the facility. Once a patient expresses the perception of pain or makes a request for pain medications, the patient will be provided with a dose of analgesic pain medication or non-pharmacological interventions will be initiated. It is the responsibility of the individual or staff member that heard the complaint to follow up and make sure that some intervention (pharmacological or otherwise) is initiated. Nurses must follow pain parameters and enter pain scales for pain medications. II. Resident #1 A. Resident status Resident #1, age 79, was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included intracerebral hemorrhage, type 2 diabetes, muscle weakness and adult failure to thrive. The 7/31/24 minimum data set (MDS) assessment revealed the resident had no brief interview for mental status (BIMS) completed due to the resident rarely/never being understood. The nursing comprehensive assessment for the neurological system, completed on 7/31/24, revealed Resident #1 was alert and oriented to himself. The resident required extensive assistance from two or more staff members for bed mobility, transfers, dressing, toileting and personal hygiene. He was always incontinent of bowel and had an indwelling catheter in place. The MDS assessment indicated the resident did not receive scheduled pain medications. He received as needed pain medication and non-pharmacological interventions for pain. The pain assessment indicated the resident did not have pain. The resident had no skin conditions upon admission and was at risk for developing pressure ulcers. B. Resident interview Resident #1 was interviewed on 8/27/24 at 8:30 a.m. Resident #1 said he had pressure sores that caused him to be in a lot of pain all the time. He said he always laid right on the sores, which caused more pain. He said the nurses put a pain patch on his back or neck and he got Tylenol for the pain but it did not relieve the pain. He said he would like to get out of bed but it was too painful. He said it was too painful to lift up his legs. Resident #1 was interviewed a second time on 8/28/24 at 10:25 a.m. Resident #1 said the CNAs did not offer to get him out of bed. He said he would like to get out of bed and into his wheelchair. He said the female CNAs that came in and helped him were not strong enough to get him out of bed. He said it took three or four of them to get his brief changed. He said they needed a couple strong men to come and get him out of bed and this had never been offered. He said his legs and back were almost always in pain when he was moved. C. Observations and staff interviews During a continuous observation on 8/27/24, beginning at 1:54 p.m. and ending at 2:40 p.m., registered nurse (RN) #2 gathered supplies to complete wound care for Resident #1's wounds. She walked into the room and two unidentified certified nurse aides (CNA) were in the room providing incontinence care. Resident #1 was yelling out and said it hurt when they rolled him to his side. The unidentified CNAs were telling the resident they had to roll him in order to clean up his bottom because he had a bowel movement. Resident #1 said they needed to get strong men to come in and roll him because the girls in there were not strong enough. Resident #1 was pushing against the CNAs trying to roll him. RN #2 explained to Resident #1 the procedure she needed to do. Resident #1 agreed and RN #2 removed two bandages from Resident #1's coccyx and right side of his bottom. He yelled out and said that hurt. RN #2 cleansed the wounds with a wound cleanser and applied medication to the wounds. Resident #1 was screaming in pain during the treatment and asked her multiple times to stop because it was so painful. RN #2 said she was almost done and they had to clean the wounds. She applied the new bandages to the wounds. RN #2 said Resident #1 was pre-medicated with Tylenol prior to the wound care. She said the resident had a stage 3 pressure ulcer to his gluteal fold and a stage 3 pressure ulcer to his right buttocks with maceration (skin around the wound is softened from moisture exposure) around the wounds. -RN #2 did not offer any pain interventions to Resident #1 during the wound care and did not stop wound care to give the resident a break when he was in pain. During a continuous observation on 8/28/24, beginning at 12:30 p.m. and ending at 1:30 p.m., the following was observed: CNA #5 was attempting to feed Resident #1 lunch. Resident #1 was refusing to eat. CNA #5 kept encouraging the resident to eat the chocolate ice cream while talking with him. He ate about ten bites. Resident #1 was talking about how much pain he was in. CNA #5 said she would tell the nurse about his pain after she fed him. During a continuous observation on 8/29/24, beginning at 12:15 p.m. and ending at 12:45 p.m. the following was observed: CNA #4 was assisting Resident #1 with his lunch. She sat him up in the bed and he yelled out to lay him back down. Resident #1 was yelling that it hurt when she sat him up. He told CNA #4 he did not want to eat because he was in so much pain. Resident #1 said if he was not in so much pain he would have liked to get up in his wheelchair. He said his back and bottom hurt. CNA #4 moved his left arm and he yelled out in pain. She said she was going to tell the nurse about his pain and come back to feed him later. D. Record review The 8/28/24 comprehensive pain evaluation (completed during the survey) revealed Resident #1 had pain frequently in his knees, back and neck. The pain frequently interfered with therapy. Resident #1 exhibited calling out, moaning and groaning when he experienced pain. The pain affected Resident #1's mood and functioning in his daily life. The assessment indicated rest, relaxation, diversion, elevation of extremities and immobilization provided him with relief. Necessary treatments that caused him pain included therapy and wound dressing changes. The assessment documented it was unable to be determined if the current pain program was working. The August 2024 CPO revealed the resident had the following physician's orders for pain management: -Lidocaine patch 4%, apply to neck and back topically every morning and at bedtime for discomfort/pain, apply patch in morning and remove at hour of sleep, ordered on 8/13/24. -Tylenol oral tablet 325 milligrams (mg), give two tablets by mouth four times a day for pain, ordered on 8/13/24. -Evaluation of pain every shift and document, ordered 7/31/24. The care plan for acute/chronic pain, initiated on 7/31/24 and revised on 8/14/24, revealed the resident had chronic pain related to generalized chronic pain. Interventions for acute/chronic pain included acknowledging the presence of pain and discomfort, listening to the resident's concerns as needed, administering pain medications per physician's order and noting effectiveness, implementing non-pharmacological interventions when able, such as positioning/support, exercise/stretching, ice packs/moist hot pack application and relaxation, monitoring for pain every shift and as needed and notifying the physician as needed for any changes. According to the August 2024 (8/1/24 to 8/27/24) medication administration record (MAR), Resident #1 was offered repositioning and a calm environment for non-pharmacological pain interventions every four hours. -A review of Resident #1's electronic medical record (EMR) did not reveal the staff offered ice packs, moist hot packs, exercise/stretching or support to Resident #1 for non-pharmacological pain interventions. -A review of Resident #1's EMR did not reveal the staff were monitoring the effectiveness of Tylenol that was administered four times a day or the repositioning and calm environment. According to the turning and repositioning August 2024 CNA task log (8/1/24 to 8/26/24), Resident #1 was repositioned a total of 49 times. He was repositioned no more than two times a day. There were no refusals of repositioning documented on the log. III. Staff interviews CNA #4 was interviewed on 8/29/24 at 12:15 p.m. CNA #4 said Resident #1 refused to eat and be repositioned frequently. She said he yelled out in pain and verbalized pain often. She said every time this happened, she told the nurse. She said the nurse told her that they would check on him when this happened but she did not know what they did to address the problems. She said it helped to explain the procedures to him before they did anything because he was scared anything they did would make him hurt. CNA #5 was interviewed on 8/28/24 at 10:30 a.m. CNA #5 said Resident #1 was incontinent of bowel and bladder and was checked and changed every two hours or as needed. She said he often yelled when they cleaned him and repositioned him. She said he got confused but was redirectable. She said the staff had to explain what they were going to do to him before doing it. She said he never got out of bed. She said she was not sure why, but he would get up every now and then with therapy. She said they offered to reposition him every two hours and charted it in the computer system. She said she assisted the nurses with his wound care. She said each time she did this, he would scream out in pain during the wound care. RN #2 was interviewed on 8/28/24 at 11:40 a.m. RN #2 said Resident #1 was repositioned and checked and changed every one to two hours. She said he had pressure ulcers on his bottom. She said he had pain when he was moved for wound care and repositioning. She said he received Tylenol scheduled and Lidocaine patches for his back and neck. RN #2 said he did not get out of bed and she was not sure why. She said there was no reason he was bedbound. CNA #6 was interviewed on 8/28/24 at 12:10 p.m. CNA #6 said the CNAs repositioned Resident #1 every two hours and assisted him at every meal. She said he often refused to eat and be repositioned. She said therapy got him out of bed sometimes but he refused to get out of bed when the CNAs offered. She said he did not want them to hurt themselves because he thought they were too small and weak to get him up safely. She said he was always in pain and he flinched in anticipation before she touched him to perform resident care. She said she made sure to explain what she would be doing before she touched him. RN #3 was interviewed on 8/29/24 at 12:00 p.m. RN #3 said Resident #1 had pain primarily with movement and when he was repositioned. He said the pain was mainly in his neck. He said he received scheduled Tylenol and Lidocaine patches for the pain. He said he documented Resident #1's pain level before administration of the Tylenol and every shift. He said non-pharmacological interventions to address pain included ice and heat packs but he never got these for the resident. RN #3 said therapy sometimes got the non-pharmacological pain interventions for the resident. He said the CNAs reported to him when the resident was having pain and he would go and check on the resident. He said he was not aware of Resident #1 refusing care due to pain. He said the Tylenol and patches helped the resident's pain. The director of nursing (DON) was interviewed on 8/29/24 at 10:00 a.m. The DON said Resident #1 was at risk for developing pressure ulcers at admission. He said on admission, Resident #1 was refusing care and could become aggressive with staff. He said Resident #1 was sleepy when he was admitted so the provider discontinued his pain medications. He said Resident #1 did experience pain in his neck and back. He said he got scheduled Tylenol and Lidocaine patches. He said he was not sure if the medications relieved the resident's pain.

Based on observations, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on one of five hallways. Specifically, the facility failed to: -Ensure the housekeeping staff completed proper hand hygiene when cleaning resident rooms and followed the appropriate guidelines for disinfectant solution; and, -Ensure the nursing staff followed enhanced barrier precautions (EBP) appropriately during resident care. Findings include: I. Failure to ensure housekeeping completed proper hand hygiene and followed appropriate disinfectant guidelines when cleaning resident rooms A. Professional reference The Center for Disease Control (CDC) (February 2024) Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 9/4/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Recommendations to clean your hands include immediately before touching a patient, before performing an aseptic technique, before moving from work on a soiled body site to a clean body site, after touching a patient or patient's surroundings, after contact with body fluids and immediately after glove removal. The 730 hp disinfectant cleaner manufacturer label was retrieved on 9/5/24 from https://picol.cahnrs.wsu.edu/Download/LabelByLegacyPath?legacyPath=/~picol/pdf/WA/66222.pdf It read in pertinent part, For use as a daily one-step cleaner/disinfectant: dilute at two ounces of product per gallon of water, pre-clean heavily soiled surfaces, apply use solution by coarse trigger sprayer to hard surfaces, spray six to eight inches from surface making sure to wet surfaces thoroughly, all surfaces must remain wet for ten minutes, wipe surfaces and let air dry. B. Facility policy and procedure The Hand Hygiene policy and procedure, revised 1/7/24, was received from the nursing home administrator (NHA) on 8/29/24 at 12:59 p.m. It documented in pertinent part, Use soap and water when hands become dirty or soiled. Use an alcohol-based hand sanitizer that contains at least 60% alcohol. Put enough sanitizer on your hands to cover all surfaces, rub your hands together until they feel dry. C. Observations During a continuous observation on 8/27/24, beginning at 10:00 a.m. and ending at 11:08 a.m., the following was observed: Housekeeper (HSKP) #1 was observed cleaning resident room [ROOM NUMBER]. She finished mopping the room and removed her dirty gloves. Without performing hand hygiene, she donned (put on) clean gloves. HSKP #1 moved to room [ROOM NUMBER]. She started cleaning the bathroom by spraying 730 hp disinfectant solution on the sink. She immediately wiped the sink with a towel. She sprayed the grab bars in the bathroom with the disinfectant and immediately wiped them down with a towel. She repeated this process with the toilet. She mopped the bathroom. She removed the dirty gloves, and without performing hand hygiene, she donned clean gloves. She moved to the bedroom and sprayed the bedside table with 730 hp disinfectant solution. She immediately wiped down the surface with a towel. She repeated this process with the window sill and the desk. She mopped and swept the floor. -HSKP #1 did not follow the correct dwell time for the 730 hp disinfectant solution. -HSKP #1 did not perform hand hygiene in between glove changes. HSKP #1 moved to room [ROOM NUMBER]. She sprayed the door handles with 730 hp disinfectant solution and immediately wiped them down with a towel. She repeated this process with the sink in the bathroom, the toilet and the commode. She mopped the bathroom and removed the dirty gloves. Without performing hand hygiene, she donned clean gloves. She sprayed the bedside table with 730 hp disinfectant solution and immediately wiped it down with a new rag. She repeated this process with the window sill and desk. She mopped the room. She removed the dirty gloves. Without performing hand hygiene, she began to wipe down the window sill in the hallway. -HSKP #1 did not follow the correct dwell time for the 730 hp disinfectant solution. -HSKP #1 did not perform hand hygiene in between glove changes. D. Staff interviews The housekeeping director (HSKD) was interviewed on 8/28/24 at 4:06 p.m. The HSKD said the dwell time for the 730 hp disinfectant solution was one minute for cleaning their standard rooms with no transmission based precautions. He said hand hygiene should be completed after removing dirty gloves and prior to donning clean gloves. -However, the 730 hp disinfectant solution manufacturer label indicated the dwell time was 10 minutes. The director of nursing (DON) was interviewed on 8/29/24 at 10:00 a.m. The DON said hand hygiene should be performed after removing dirty gloves. He said hand hygiene should be performed prior to donning clean gloves. II. Failure to ensure nursing staff followed enhanced barrier precautions (EBP) appropriately during resident cares A. Facility policy and procedure The Enhanced Barrier Precautions policy and procedure, issued 3/27/24, was received from the NHA on 8/29/24 at 12:59 p.m. It documented in pertinent part, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce the number of multidrug resistant organisms that employs targeted gown and glove use during high-contact resident care activities. EBP are required for patients with wounds and/or indwelling medical devices. High-contact care activities included dressing, bathing, transferring, working with patients in the therapy gym, providing hygiene, changing linens, changing briefs or assisting with toileting, device care and wound care. B. Observations During a continuous observation, beginning on 8/27/24 at 10:00 a.m. and ending at 11:08 a.m, the following was observed: An unidentified certified nursing assistant (CNA) entered into room [ROOM NUMBER] after an unidentified transportation staff member assisted the resident to his room after the resident returned from a doctor's appointment. He had an indwelling foley catheter device and was on EBP. There was a sign posted outside the room and a cart that contained gowns and gloves outside his door. The unidentified CNA donned clean gloves and walked into the room. She transferred the resident from his wheelchair to his bed using a gait belt. The unidentified CNA moved the catheter drainage bag from the wheelchair and hooked it onto the bottom of his bed. She walked out of his room and removed the dirty gloves. She washed her hands. -The CNA did not put a gown on to provide resident care to a resident on EBP. During an observation on 8/28/24 at 3:17 p.m., the following was observed: The resident in room [ROOM NUMBER] initiated his call light . The staffing coordinator (SC) walked into the room. She grabbed gloves on her way into the room. There was a sign on the door that indicated the resident was on EBP. There was a cart stocked with gowns and gloves outside his room. She asked how she could help him and he asked to get out of bed. She put a gait belt on him and assisted him out of bed and into a wheelchair. She moved his catheter drainage bag from the bed to his wheelchair. She removed her gloves and washed her hands. -The SC did not wear a gown when she assisted the resident with transferring and when handling a resident who had a foley catheter that was on EBP. C. Staff interviews The DON was interviewed on 8/29/24 at 10:00 a.m. The DON said EBP should be followed when providing resident care for those with medical devices or chronic wounds. He said high contact activity included when the staff members were in direct contact with the resident. He said some of these activities included toileting residents, changing linens, dressing residents, transferring residents and providing wound care. He said staff should put a gown and gloves on prior to providing these care activities with residents on EBP.

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process; and, Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous friction on the surfaces of the lathered fingers, fingertips, areas between the fingers, hands and arms for at least 15 seconds, followed by; 2. Thorough rinsing under clean, running warm water; and 3. Immediately follow the cleaning procedure with thorough drying of cleaned hands and arms with disposable or single use towels or a mechanical hand-drying device. B. Observations Observation of the meal service was conducted on 4/24/23 at 10:45 a.m. Dietary aide (DA) #1 was observed setting up for the afternoon lunch meal. DA #1 walked over to the oven and opened the door with her gloved hand and retrieved a large metal container of lasagna. She walked over to the serving table and placed the lasagna on the counter. She proceeded to remove the clear saran wrap from the metal container. She rolled the clear wrap into her hand and proceeded to throw it in the trash can touching the side of the trash can with her hand. She wiped her hand on the side of her apron. DA #1 repeated this process for all of the food items for the afternoon menu. DA #1 reached down under the heating table and grabbed several serving scoops and proceeded to place them into the metal food containers on the heating table. She then would grab the metal lids and place them on the food items covering them until the service began. DA #1 then proceeded to take the temperature of the food. She took a thermometer and took the temperature of the lasagna. She proceeded to grab a thermometer and several sanitizing wipes. She took the temperature of the food and then wiped the thermometer with the alcohol wipe. She then grabbed a pen from her pocket and documented the temperature of the food. This was repeated for all of the food items on the serving line. She then grabbed the used alcohol wipes and again threw them into the trash can. DA #1 then reached into the sanitizing bucket and grabbed a rag and wiped the counter on the serving line. She replaced the rag into the sanitizing bucket and wiped her hands on the side of her pants. She then proceeded to start serving the meals. DA #1 was preparing a hamburger for a special order. She reached in the bag with her gloved hand and retrieved a hamburger bun. She reached under the counter and grabbed a frying pan. She placed it on the stove and placed the buns into the pan. She buttered the hamburger buns holding them in her gloved hand and placed them into the pan. She then walked over to the heating oven and retrieved a hamburger patty from a plate. She removed the clear wrap from the plate and rolled it into her hand and placed it into the trash can. She again reached under the counter and retrieved another pan placing it on the stove. She placed the hamburger patties into the pan and turned the stove burners on. She returned to the serving line and proceeded to serve other residents ' meals. The hamburger patties were cooked and she grabbed the hamburger buns and placed them on a plate. She then opened the sandwich area lid and retrieved a slice of cheese, slice of onion and other condiments out of the sandwich area. She grabbed a slice of cheese with her gloves and placed it on the bun. She then grabbed several slices of onion with her gloved hand and placed them on the bun. She then placed the cooked hamburger patty on the bun and then grabbed the other slice of bun and placed it on top of the hamburger. She then placed the hamburger on the cutting board and proceeded to cut it holding it with her gloved hand and then she plated it and placed it on the counter. DA #1 then returned to serving the rest of the residents ' meals. DA #1 did not perform hand hygiene during this process. The dietary manager (DM) was observed in and out of the walk-in cooler getting the side deserts, salad and other items for lunch. The DM was observed going in and out of the walk-in cooler and into his office during this process. He went into the storage room and retrieved some Styrofoam meal containers. He walked into the walk-in cooler and retrieved a bag of lettuce. He opened the bag of lettuce with his gloved hand and proceeded to grab several handfuls of lettuce and place them into the Styrofoam container. He wiped his gloved hand on the side of his pants. He wrapped the lettuce and placed it back into the walk-in cooler opening the door with his gloved hand. He returned with a tomato. He cut the tomatoes on the cutting board and placed the pieces into the salad. He then walked over to the sandwich area and grabbed several handfuls of shredded cheese with his gloved hand and placed them on the salad on the Styrofoam container and closed it and placed it on a metal rack. He then walked into the walk-in cooler and grabbed the handle with his gloved hand. He returned with a bag of red grapes and proceeded to wash them in the sink. He grabbed a handful of grapes and placed them into a dessert dish. He wiped his hands on the side of his pants. He replaced the grapes back into the walk-in cooler. The DM then assisted the DA #1 with serving the afternoon meals. The DM did not perform hand hygiene during this process. DA #3 was observed placing the residents ' drinks on the meal trays and then placing them into the warming carts. DA #3 was observed several times walking out of the kitchen to the dining room and then returning to the kitchen area. DA #3 was observed opening the residents ' drinks and adding thickener to the drinks. She removed the lid with her hand and squirted two pumps of thickener into the cup. She then reached over and retrieved a spoon and proceeded to stir the thickener into the drinks and then replace the lids. She was observed wiping her hands on the side of her apron after getting the thickener on her hand. DA #3 was observed doing this repeatedly during the serving process. DA #3 did not perform hand hygiene during this process. C. Staff interview The DM was interviewed on 4/24/23 1:58 p.m. He said all kitchen staff needed to wash their hands when their hands become contaminated. He said all staff must wash their hands before handling or serving food. He said staff should never touch ready to eat foods with their bare hands. He said they should use serving tongs even if they have gloves on. Staff should wash their hands when they leave the kitchen and dining area. The DM said all dietary staff should wash their hands between tasks to avoid cross contamination. II. Food temperatures A. Professional reference According to the United States Public Health Service Food and Drug Administration (FDA) 2022 Food Code 3-403.11 (A) pg. 36 Time/Temperature Control for Safety Food (TCS) that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees C (165 degrees F) for 15 seconds. B. Observations and staff interview On 4/24/23 at 10:45 a.m., DA #1 was observed preparing minced moist mechanical soft meals of grilled chicken and meat lasagna that was being held for lunch service. DA #1 proceeded to the warming oven and retrieved a small metal container of chicken. She placed the grilled chicken into the blender and proceeded to mince the chicken. She grabbed the small metal container with broth and poured it into the blender until she reached the correct consistency of the minced moist grilled chicken. She grabbed a small metal container and sprayed it with cooking oil. She poured the minced moist grill chicken into the metal container and placed it on the counter. She proceeded to start wrapping aluminum foil on the container. The surveyor requested for the cook to take temperatures of the puree food. The cook stated the temperature of the grilled chicken was 118 degrees F. She then wrapped the metal container and placed it into the warming oven. She proceeded to complete the same process for the lasagna. She then placed seven large pieces of lasagna into the blender and proceeded to mince the lasagna. After getting it to the correct consistency she grabbed another metal pan and poured the minced moist lasagna into the pan. She placed it on the counter and took the temperature, which was 120 degrees F. She wrapped it with aluminum foil and placed it into the oven. -At 11:00 a.m., the DA #1 was asked if she checked the temperature of the minced moist foods after pureeing them. The cook said, No, I do not, but I would take the temperatures before serving them and they should be at 150 degrees F. -At 11:20 a.m., DA #1 took the temperatures of the grilled chicken and the lasagna. The temperature of the grilled chicken was 128 degrees F and the lasagna was at 130 degrees F. -At 11:39 a.m., the DA #1 again took the temperature of all items listed above. The grilled chicken was at 145 degrees F and the lasagna was at 150 degrees F. -At 11:45 a.m. the DA #1 again took the temperature of all items listed above. The grilled chicken was at 160 degrees F and the lasagna was at 163 degrees F. C. Additional interview The DM was interviewed on 4/23/15/23 at 1:58 p.m. He said he was aware that the temperatures of the modified food dropped at times. He said It's my expectation that the food was ok as long as it reached 165 degrees F before serving. He said dietary staff would be educated immediately to ensure the modified consistency of food reached proper temperatures and time frames. III. Cutting Boards A. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (updated 1/1/19), page 132, and Cutting surfaces that are scratched and scored must be resurfaced so as to be easily cleaned, or be discarded when these surfaces can no longer be effectively cleaned and sanitized. B. Observation The initial kitchen tour conducted on 4/19/23 at 8:30 a.m. revealed four large cutting boards. There were green, red, white and brown cutting boards as well as a large white cutting board at the sandwich prep area; all cutting boards were heavily scored and stained. On 4/20/23 at 8:32 a.m., the DM was cutting toast on the green cutting board. On 4/24/23 at 10:40 a.m. during kitchen observations DM was observed cutting vegetables on the red cutting board. C. Staff Interview The DM was interviewed on 4/24/23 1:58 p.m. The DM was told of the observations of the cutting boards in the kitchen. He acknowledged the cutting boards were visibly stained and showed wear. He said he had purchased his cutting board from another supplier but he did not think they were made of good quality material. He said he would replace them immediately. He said the deep scratches could be a potential for bacteria to grow.

Based on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure backflow prevention devices were installed on hoses in two maintenance closets, increasing the risk of contamination to the facility's main water supply. Findings include: I. Observation Observations of the resident living environment conducted on 4/24/23 at 3:30 p.m. revealed: The hoses on the second and third floor maintenance closets did not have a backflow prevention valve on them. The hose on the third floor was long enough to sit on the bottom of the drain pan. The hose on the second floor was approximately 25 feet long and coiled and was sitting at the bottom of the sink pan. There was visible standing water at the base of both of the sink pans. II. Staff Interview The housekeeping supervisor (HKS) was interviewed on 4/25/23 at 9:40 a.m. He said the hoses in the maintenance closet should have had a backflow prevention valve on them. He said he would install them immediately.

Based on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 17 of 44 resident rooms in four hallways. Specifically, the facility failed to ensure walls, and ventilation fans were cleaned and properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 4/24/23 at 3:30 p.m. revealed: room [ROOM NUMBER]: The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The wall next to the resident's restroom had peeling and chipped sheetrock approximately four feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The wall next to the resident's restroom had chipped and peeling sheetrock approximately four two feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. room [ROOM NUMBER]: The wall next to the resident's restroom had chipped and peeling sheetrock approximately three feet high by two inches wide. The exhaust fan in the resident's restroom had a large accumulation of dust which was affecting the functionality of the fan. The certified nurse station on the second floor had chipped and damaged sheetrock approximately five inches wide by four inches wide. room [ROOM NUMBER]: There was a metal bracket approximately four inches by three inches wide from the missing coat rack. room [ROOM NUMBER]: The wall next to the resident's restroom had a large chipped and peeling sheetrock approximately four feet high by five inches wide. The wall next to room [ROOM NUMBER] had chipped and damaged sheet rock approximately five inches wide by four inches wide with the metal corner visible. room [ROOM NUMBER]: The counter next to the resident's bed had a section of missing laminate approximately five inches long by two inches wide. II. Environmental tour and staff interview The environmental tour was conducted with the maintenance supervisor (MS) on 4/25/23 at 9:35 a.m. The above detailed observations were reviewed. The MS documented the environmental concerns. The MS said the facility utilized a computer system to identify environmental issues. The MS said he did not have any repair requisition requests for the above-mentioned items. The MS said the above-mentioned damage should have been repaired and addressed in a timely manner. The MS said the facility had a flood about two months ago and it caused some issues with the heating ventilation air conditioner system. He said the dirty exhaust fans were a result of the filters not being changed. He said the dirty exhaust fans did not allow the functionality of the exhaust fans and could be a fire hazard. He said the filters would be changed immediately and the vents cleaned.

Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring for one (#9) of two residents reviewed out of 28 sample residents. Specifically, the facility failed to ensure Resident #9's bilateral heels were offloaded while in bed. Findings include: I. Professional reference The National Pressure Injury Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers accessed on 4/27/23 from https://npiap.com/ read, steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. II. Facility policy and procedure The Pressure Ulcer policy, revised 2/8/21, was provided by the nursing home administrator (NHA) on 4/25/23 at 12:25 p.m. It read in pertinent part: The (name) will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards. III. Resident #9 A. Resident status Resident #9, age 90, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included congestive heart failure, acute respiratory failure, acute kidney failure and assistance with personal care. According to the 3/13/23 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 14 out of 15. The resident had no behavioral symptoms. She required extensive assistance for bed mobility, transfers, grooming and toilet use. The MDS assessment coded the resident was at risk for pressure ulcers. The MDS assessment coded the resident as not having any behaviors or refusal of care. B. Observations and interview On 4/19/23 at 10:21 a.m. the resident was lying in bed sleeping. The resident did not have her feet off loaded. On 4/20/23 at 9:14 a.m. the resident was lying in bed sleeping. The resident did not have her feet off loaded. -At 10:33 a.m. the resident was lying in bed eating her ice cream. The resident did not have her feet off loaded. Resident #9 said, They never put anything under my feet or have I been asked to have a pillow under my feet. -At 11:02 a.m. an unidentified certified nurse aide (CNA) asked the resident if she needed anything. The resident was not offered to be repositioned or offloaded. On 4/24/23 at 2:54 p.m. licensed practical nurse (LPN) #2 observed the resident did not have her feet off loaded. LPN #1 placed the pillow under her ankles to offload her heels from the mattress. During this care, the resident was cooperative and friendly with LPN #2. LPN #2 said according to the tasks and the care plan Resident #9 feet should be offloaded while the resident was in bed. She said a negative outcome would be the resident's heels would develop redness, cause skin breakdown and become a pressure ulcer. C. Record review The care plan, initiated 3/9/23 and revised 3/18/23, identified the resident had actual/potential skin breakdown or surgical wound(s) related to: fragile skin moisture associated skin damage (MASD) sacral wound left heel red. Intervention included Braden scale every week per protocol, and skin assessment as ordered and as needed. Pressure relieving mattress per facility protocol and as ordered. Off load heels as tolerated in bed. The April 2023 CPO showed an order for the resident to monitor bilateral heels every shift for signs and symptoms of skin breakdown, notify medical doctor (MD) and wound care specialist of complications. Start date 3/9/23. The Braden scale completed on 4/17/23 showed the resident was at mild risk for pressure ulcers with a score of 17. III. Interviews The director of nurses (DON) was interviewed on 4/25/23 at 9:05 a.m. The DON said the resident was at mild risk for pressure ulcers due to the moisture associated skin damage (MASD). She said that she should be repositioned at least every two hours and feet offloaded while in bed. The DON said a negative outcome would be the Resident #9 could develop a pressure ulcer. The DON said she had started to re-educate staff on offloading resident's feet to prevent pressure ulcers.

Based on observations, interviews, and record review, the facility failed to implement interventions to reduce hazards and risks for falls for two (#198 and #197) residents out of five residents reviewed for falls out of 28 sample residents. Specifically, the facility failed to ensure Resident #197 and #198 were provided the interventions available to prevent repeated falls and staff were aware of person-centered interventions. Findings include: I. Facility policy and procedure The Fall Prevention Program policy, revised August 2022, was provided by the nursing home administrator (NHA) on 4/24/23 at 4:06 p.m. It read in pertinent part, Any patient deemed to be high risk will have the following interventions implemented or at least considered: -Low bed (or lower our standard bed to its lowest position) -Bedside floor pads on both sides of bed. For post falls: -Determine what interventions need to be implemented to prevent further falls. Intervention will be reviewed by Interdisciplinary Team for appropriate interventions and care plan will be updated. -Initiate orders and/or tasks for fall prevention and for skin injuries if indicated. II. Resident #198 A. Resident status Resident #198, age 75, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease and major depressive disorder. The 4/17/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted with the resident indicated by he was rarely to never understood or understands. A staff interview showed the resident had severe cognitive impairments. The resident required extensive assistance with bed mobility, transfers, walking, toileting, dressing and personal hygiene. Falls were not coded. B. Observations and interview Resident #198 was observed on 4/19/23 at 9:00 a.m laying in his bed in room. The bed was not in the lowest position and no fall mat present. There was no yellow fall star on the resident's door (as indicated for resident with fall risk, see interviews below). Resident #198 was observed at 9:39 a.m. sitting on the edge of his bed in room. The bed was not in the lowest position and no fall mat present. There was no yellow fall star on the resident's door. Certified nurse aide (CNA) #4 was interviewed on 4/19/23 at 12:45 p.m. She stated Resident #198's bed was in the lowest position. She then checked on the resident's bed and discovered it was not in the low position. Resident #198 was observed on 4/20/23 at 3:00 p.m. laying in bed in his room. The bed was not in the lowest position and the resident was not wearing non-grip socks. There was no yellow fall star on the resident's door. Resident #198 was observed on 4/24/23 at 9:03 a.m. laying in his bed in room. He was agitated and moving his legs. There was no fall mat present and no yellow fall star on the resident's door. Resident #198 was observed at 12:00 p.m. laying in bed in his room. He was agitated and moving his legs. There was no fall mat present and the bed was not in the lowest position. C. Record review The comprehensive care plan, revised on 4/14/23, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility. History of falls and limited mobility. Interventions were to ensure call light is within reach, use of handrails, environment free of clutter, commonly used articles within reach, physical/occupational therapy to evaluate and treat, frequent rounds on resident, and ensure resident wears proper non-slip footwear. Post fall evaluations dated 4/14/23 revealed the resident had an unwitnessed fall in the hallway and was found on the floor. The resident was unable to explain the fall and it was determined the fall was due to wandering, poor safety awareness, and refusals for assistance. Recommended to initiate the 4 P's (asking if the resident needs to use the restroom, needed repositioning, had common items in reach or asking if the resident is in pain). Post fall evaluations dated 4/20/23 revealed the resident had an unwitnessed fall in his room kneeling on the floor. The resident was unable to explain the fall, and it was determined the fall was due to confusion and poor safety awareness. Recommended to use non-skid socks, check for need for toileting, place bed in lowest position, and add fall mats. The April 2023 facility tasks (a care directive for CNAs revealed the fall interventions were as follows: -Ask the 4 P's started on 4/21/23. -Gripper socks in place started on 4/20/23. -Bed in lowest position started on 4/6/23. -Yellow falling star on resident's door started on 4/24/23. -Leave resident's door open unless providing care started on 4/6/23. -Round on resident frequently started on 4/7/23. -Fall mats while in bed started on 4/21/23. III. Resident #197 A. Resident status Resident #197, age 93, was admitted on [DATE] and passed away 4/19/23. According to the April 2023 CPO, diagnoses included pulmonary embolism, diabetes, and chronic kidney disease. The 4/11/23 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of eight out of 15. The resident required extensive assistance with bed mobility and toileting. The resident required limited assistance with dressing, personal hygiene, walking, and transfers. Falls were not coded. B. Observations Resident #197 was observed on 4/19/23 at 9:00 a.m laying in his bed in room. The bed was not in the lowest position. There was no yellow fall star on the resident's door. Resident #197 was observed at 1:15 p.m. being assisted to his room by the activities director (AD) and he stated to the AD that he did not feel well and wanted to lie down. CNA #4 stopped the resident, and advised the AD the resident's wife was not present to watch him in his room so he needed to be taken to sit at the nurses station. At 1:24 p.m. a nurse was observed taking the resident to his room and assisted him to lie down. The resident's bed was not in the lowest position. At 1:28 p.m. the resident began calling for help. CNA #4 came to the resident's room at 1:38 p.m., got him out of his bed and took him back to the nurses station. C. Record review The comprehensive care plan initiated on 4/7/23, revealed the resident was at risk for falls related to impaired mobility secondary to weakness and debility. History of falls and limited mobility. Interventions were to ensure call light is within reach, use of handrails, environment free of clutter, commonly used articles within reach, physical/occupational therapy to evaluate and treat, frequent rounds on resident, use yellow fall star on door, ensure resident wears proper non-slip footwear, and wife stays at night. Post fall evaluations dated 4/12/23 revealed the resident had an unwitnessed fall in his room while his wife was sleeping in the room. The resident was trying to transfer himself. Recommended to redirect and conduct frequent rounding. Post fall evaluations dated 4/19/23 revealed the resident had an unwitnessed fall in his room and was found on the floor. The resident was attempting to get out of his wheelchair without assistance. Recommended for wife to sit in room with the resident daily to prevent falling. The April 2023 facility tasks revealed the fall interventions were as follows: -Ask the 4 P's started on 4/12/23. -Gripper socks in place started on 4/12/23. -Bed in lowest position started on 4/12/23. -Yellow falling star on resident's door started on 4/12/23. -Leave resident's door open unless providing care started on 4/13/23. -Round on resident frequently started on 4/7/23. III. Staff interviews CNA #4 was interviewed on 4/24/23 at 9:03 a.m. She said fall interventions for Resident #198 were to redirect him, keep his bed in the lowest position, frequent checks and ensure he had a yellow fall indicator star on his door. During interview, she checked on the fall star for Resident #198 and discovered there was not one on his door. CNA #4 stated fall interventions for Resident #197 consisted of frequent checks, making sure his door remained open and putting him at the nurses station. The fall precautions would be found in the tasks. The director of nursing (DON) was interviewed on 4/24/23 at 2:28 p.m. She stated the 4 P's were the facility's fall program. The staff were to check the resident to determine if they needed to use the restroom, needed to be repositioned, had commonly used items in reach and were not in pain. She acknowledged sitting Resident #197 at the nurses station was not a fall intervention. She said she had staff available that could have provided him one-on-one supervision in his room until his wife arrived. The DON said the wife should not be responsible for ensuring the resident did not fall. The staff should be doing frequent checks even when the wife was visiting. She said the CNAs were responsible for putting magnetic yellow fall stars on the resident's door to indicate they are a high fall risk. The DON stated the facility did not use fall mats because they were considered a restraint but did not explain how the mats were a restraint. The DON said fall interventions for Resident #198 were the 4 P's. She said she helped with entering the tasks for the CNAs but was not aware that staff had put fall mats as an intervention. She was not aware that his bed was not in the lowest position and he did not have a yellow star on his door but the CNAs were signing off that those things were in place. The DON said that she did chart audits but missed the fall mats as interventions.

Based on observation, record review and interviews the facility failed to maintain communication with the hospice provider, including how the communication would be documented between the facility and the provider for two (#198 and #104) of two residents reviewed for hospice care services out of five residents reviewed for hospicare care out of 28 sample residents. Specifically, the facility failed to: -Demonstrate documentation of a collaboration of care between the facility and the hospice provider for Resident #198; and, -Ensure medication orders from the hospice provider were received and administered for Resident #104. Findings include: I. Resident #198 A. Resident status Resident #198, age 75, was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease and major depressive disorder. The 4/17/23 minimum data set (MDS) assessment revealed a brief interview of mental status (BIMS) was not conducted with the resident indicated by he was rarely to never understood or understands. A staff interview showed the resident had severe cognitive impairment. Hospice care was not coded. B. Record review The April 2023 CPO revealed the resident admitted with an order for hospice services dated 4/6/23. The resident's comprehensive care plan was reviewed and the plan for hospice was initiated on 4/6/23, with the goal to have effective pain control. Pertinent care plan interventions initiated 4/6/23 included: -Acknowledge presence of pain and discomfort. -Administer pain medication per physician order. -Implement non-pharmacological interventions as possible. -Monitor for pain every shift. -Notify the physician as needed for any changes. -Refer to hospice if required. -The care plan did not delineate the care provided by the hospice provider and did not indicate the frequency of their visits. -A review of the resident's progress notes dated 4/5/23 to 4/23/23 revealed the progress notes failed to show regular hospice visits or document the services hospice provided to Resident #198 when they visited him. -A review of scanned documents failed to reveal hospice visit notes. C. Staff interviews Licensed practical nurse (LPN) #2was interviewed on 4/24/23 at 9:19 a.m. She stated there was a hospice communication binder at the nurses station for Resident #198. She was unable to locate the binder. After ten minutes of looking for the binder, LPN #3 returned and stated she was unable to locate the binder and there was no hospice communication binder for Resident #198. The hospice nurse gave the LPN verbal visit reports only. The director of nursing (DON) was interviewed on 4/24/23 at 9:27 a.m. She said Resident #198's hospice provider did not provide the facility with a communication binder to leave visit notes or orders. The hospice provider gave the hospice visit notes to the resident's nurse and they gave the notes to the DON. The DON would put the hospice visit notes in the mailbox for the medical record clerk to scan into the resident's electronic medical record. On 4/24/23 at 11:47 a.m., an email was sent to the nursing home administrator (NHA) requesting the hospice visit notes for Resident #198. Daily hospice visit notes were received from NHA at 3:18 p.m. for dates 4/5/23 to 4/23/23. The NHA was interviewed on 4/24/23 at 3:50 p.m. She stated she was uncertain where the hospice visit notes that she had provided had been located. She believed the notes had been in a pile of documents to scan in the medical records office. She was unable to explain why the delay in uploading Resident #198's hospice visit notes had gone back to 4/5/23, his date of admission. The DON was interviewed on 4/24/23 at 4:00 p.m. She stated she had requested the hospice visit notes from the medical records clerk who informed her there were no outstanding hospice notes to scan into Resident#198's chart. The facility's admissions coordinator had reached out to the hospice provider and requested faxed visit notes. The DON stated she had been told by the hospice provider they did not provide communication binders for resident's in rehabilitation facilities on respite (short stay) care. The hospice nurse would give a verbal report to the facility nurse after the patient visit. According to the DON, she said the hospice provider was to use a communication binder or provide documented visit notes to the facility so the facility could include those notes into the resident's medical record. The admissions coordinator (ADM) was interviewed on 4/25/23 at 8:50 a.m. She stated she had reached out to Resident #198's hospice provider on 4/24/23 to request visit notes for 4/5/23 to 4/23/23. She said she did that to assist the facility but that was not a normal practice for receiving hospice notes. The hospice clinical director (HCD) was interviewed on 4/25/23 at 8:53 a.m. She said the hospice nurse should be having conversations with the resident's nurse and providing orders when they visit the resident. Their normal practice for long term or short stay residents was to prepare a communication binder for the facility. The decision to have a communication binder or not to was a facility driven decision and based on the facility's preference. The facility for Resident #198 had declined a binder stating they did not have a place for a binder. The hospice provider did not normally provide their internal visit notes taken on the tablets to the facility. The HCD acknowledged that with the absence of a binder and lack of documentation following a visit could provide a lack in the collaboration of care for the resident. She was unaware when the hospice nurses, CNAs, chaplains and social workers visited Resident#198. She said when hospice staff visited they gave a report to the resident's nurse and a progress note was not being made in his resident's electronic medical record. 31820 II. Resident # 104 A. Resident status Resident #104, age 89, was admitted on [DATE] and discharged on [DATE]. According to the April 2023 computerized physicians orders (CPO), diagnoses included lung cancer, Parkinson's disease, and shingles. The minimum data set (MDS) assessment had not been completed for the short respite stay. The resident recieved hospice services during the stay. B. Record review The care plan, initiated 4/19/23, identified the resident was on strict transmission based precautions due to shingles. The intervention was transmission based precautions and to have all care and services be limited to the resident's room. The April 2023 CPO did not identify Acyclovir. The 4/17/23 Hospice nurse visit note included, Were all medications reviewed for effectiveness, side effects, interactions, duplicative action, and needed lab monitoring? Yes, medication changes required. Indicate medications changed: Acyclovir 800 milligrams (mg) five times a day for seven days. C. Interviews Licensed practical nurse (LPN) #4 was interviewed on 4/24/23 at 9:05 a.m. She said when the facility received a physician order either verbal or written, the orders were entered into the electronic record and sent to the pharmacy for a fill. She said the pharmacy delivered medications a couple times a day. She said the facility had a pyxis machine (a machine with various medications monitored by the pharmacy) they could utilize if necessary. At 2:31 p.m. she and the staff could review the hospice notes if the hospice providers left a note. She said she had not observed hospice notes for Resident #104. The director of nursing (DON) was interviewed on 4/24/23 at 3:42 p.m. She said any orders were verified by her and the floor nurses. The floor nurses could enter orders into the resident's electronic records and send the order to the pharmacy. She said if a verbal order was given to the floor nurse, they were trained to input the orders into the resident's electronic record. She said she checked the fax daily for new orders. She said she was not aware of the Acyclovir order for shingles for Resident #104. On 4/25/23 at 9:26 a.m. the DON said she interviewed the floor staff and none of the nurses she spoke to knew of an order for Acyclovir. She said the hospice provider had not notified the facility of the order. She said a new medication ordered by hospice would be provided by hospice and the facility had no record of receiving the medication. She said the facility needed to improve a process to communicate more effectively with the hospice provider. The hospice clinical director (HCD) was interviewed on 4/26/23 at 9:45 a.m. She said the nurse she interviewed reported to her that a hospice staff had given the facility floor nurse at the time a verbal order for the Acyclovir. She said she could not locate a faxed order to the facility. She said a nurse at the facility had signed for a delivery of the Acyclovir. She said the medication was sent home with Resident #104 upon discharge from the facility. She said she had contacted the hospice medical director and was told there was not a negative outcome for not starting the medication while in the facility, and the hospice provider would be starting the medication since the resident had returned home. The DON was interviewed on 4/26/23 at 10:17 a.m. She said normally orders from hospice providers were received by fax, or if verbal there would be a form. She said medications ordered by the hospice provider were provided by them. She said none of the interviewed staff verified the arrival of the medication. She said the facility would be revising communication with the hospice providers to try to avoid the identified situation from occurring again.

Based on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for pressure ulcers out of 10 total sample residents, received care consistent with professional standards of practice to prevent pressure injuries. Specifically, the facility failed to ensure interventions for the prevention of two pressure ulcers were timely implemented for Resident #2. I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 3/9/22, pressure ulcer classification is as follows: Category/Stage I: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable 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 I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). 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. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (3/9/22), Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Individuals with a medical device in situ are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local [CONDITION(S)], as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility policy The Pressure Ulcer policy, revised 2/8/21, was provided by the facility administrator (NHA) on 2/9/22 at 2:00 p.m., read in parts: The (Facility) will provide the necessary requirements to ensure that a patient receives the treatment and care in accordance with professional standards of practice .In addition they shall describe and document the following .Patients mobility status .The physician will assist identifying factors contributing or predisposing patients to skin break down . III. Resident status Resident #2, age 83, was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/29/22 minimum data set (MDS) assessment revealed severely impaired cognition with a brief interview for mental status (BIMS) score six out of 15. She required extensive assistance of two staff with bed mobility, transfers, dressing, and personal hygiene, extensive assistance of one person with toilet use, and supervision with one person assist with eating. She was frequently incontinent of urine. Weight was 98 pounds and no weight loss was documented. No pressure injuries noted. Medications included an anticoagulant daily. The resident was discharged to an assisted living facility on 2/10/22. IV. Record review Care Plan -I need assistance with transfers/toileting related to impaired mobility secondary to weakness and debility. Date initiated: 1/23/22. -Occupational therapy services are indicated for Resident due to decreased ability to perform bed mobility, decreased ability to transfer, decreased ADL (activities of daily living) ability, decreased balance, decreased strength, postoperative precautions or restrictions (posterior hip precautions). Date initiated: 1/24/22 -I have a potential and/or am at risk for inability to maintain my nutrition d/t underweight BMI (body mass index), weight loss d/t (due to) poor app/po (appetite/oral) intake r/t (related to) Alzheimer's dementia, and pressure injuries. Date Initiated: 1/25/22 -Resident) has stage I (one) pressure injury of R (right) heel and DTI (deep tissue injury) of L (left) heel potential for pressure ulcer development r/t (related to): hip fx (fracture), decreased mobility, use of abd (abduction) pillow. WCC (wound care certified) notified of wounds on 2/7/22 and assessment completed that day. Date Initiated 2/7/2022. Interventions included: Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Offloading boots to be worn when in bed. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Date Initiated: 2/7/22 The facility failed to timely implement appropriate approaches (offloading boots) to prevent pressure injuries. Skin evaluations The Skin Evaluation dated 1/23/22 revealed: Heels/coccyx intact. The Skin Evaluation dated 1/25/22 revealed: Heels/coccyx intact, surgical incision to right hip covered w/ (with) clear dressing. No s/sx (signs/symptoms) adverse reactions. The Braden Scale for Predicting Pressure Sore Risk (a tool used to determine a resident's risk for pressure ulcer development), dated 1/25/22, documented Resident #2 was at low risk for developing pressure ulcers with score of 17. The January 2022 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Boost Plus (nutritional supplement), two times a day for weight support, order date 1/25/22 -Magic Cup (nutritional supplement), one time a day for weight support, order date 1/25/22 The Braden Scale for Predicting Pressure Sore Risk, dated 2/1/22, documented Resident #2 was at moderate risk for developing pressure ulcers with score of 14. The Skin Evaluation dated 2/1/22 revealed: Bruising to BUE (bilateral upper extremities); surgical incision to right hip, with staples and surgical glue in place. On 2/2/22 a registered dietician (RD) documented: RD visited pt during lunch. CNA (certified nurse aide) (name) had assisted pt (patient) with meal set-up and came by to frequently encourage pt (patient) to eat/drink/swallow. RD encouraged pt (patient) during meal as well. When asked if the food tasted good, pt (patient) said yes. RD would offer different items from the meal (sandwich, soup, jello, chips, apple juice) pt (patient) would sometimes say no. Even when pt (patient) said yes, she would not always pick up more to eat. Pt (patient) chewing very slowly. Pt consumed ~25% (approximately 25 percent) of the meal. CNA (certified nurse aide) (name) states she will offer the patient a snack between lunch and dinner to encourage po (oral) intake. Pt (patient) consuming 25% most of Magic Cup and Boost. RD called pt's (patient ' s) dtr (daughter) (name) to provide nutrition/weight update . RD rec'd (recorded) adding snacks between breakfast, lunch, and dinner to promote po (oral) intake. Dtr (daughter) agrees to PBJ (peanut butter and jelly) sandwich cut in fourths. Also think pt (patient) would like mashed potatoes and gravy added to dinners. RD notified kitchen and added CNA task for snacks. RD rec'd (recorded) that we cont (continue) to offer Boost/Magic Cup. Dtr (daughter) states pt (patient) eats best when encourage to eat/swallow/drink during meals. RD explained to dtr (daughter) that is what CNA and RD did for pt (patient) during much today and pt (patient) was still eating slowly/minimally. RD added CNA task to assist with meal set-up and encourage pt (patient) frequently during meals to cont (continue) to help promote po (oral) intake. Dtr (daughter) denies further food/nutrition questions or concerns at this time. MD (physician) notified. Discussed with IDT (interdisciplinary team). RD to monitor. On 2/4/22 a nurse documented: Patient has a swelling, warm to the touch and redness on her ankle. Physician was notified. Nursing note did not specify left or right ankle and did not address bilateral heels skin assessment. On 2/5/22 a physician documented: Patient was noted to have significant pain in her left ankle and was having difficult time putting any weight on her left foot. There was some concern about possible redness and warmth in that foot. Subsequently stat labs ordered including CBC (complete blood count) and ESR (erythrocyte sedimentation rate, a blood test that detects and monitors inflammation in the body) and CRP (C-reactive protein). So far CBC and CRP results are available and they are unremarkable with normal white count and normal CRP levels for inflammation. Patient's daughter wanted me to check her out and as such she was examined today. Patient does have some bruising apparently with some swelling in her left ankle on the lateral aspect. She does have significant tenderness in her left lower extremity especially in her ankle area on any manipulation . Left heel pressure area–patient's heels have been floated. Discussed with nursing staff including director of nursing. On 2/5/22 an SBAR (situation, background, assessment and recommendation) revealed: Black eschar to left heel. Patient reports increased pain to left heel. Float on pillow and [MEDICATION(S)] for pain. Elevate heels on pillows. On 2/7/22 a physical therapist (PT WCC-wound care certified) documented: This clinician was alerted on this date by DON (director of nursing) that (physician) and family reported pressure injury to B (bilateral) heels. Completed assessment. L (left) heel has intact skin that is dark purple/black in color with bogginess noted with palpation. Patient also had pain with palpation. Area cleansed, measured and dressed with sure prep and foam. No drainage noted and surrounding skin intact without redness or signs of infection. R (right) heel assessment completed as well. There is an area of non-blanching red skin that is not boggy with palpation and no pain. Area cleansed, measured and dressed with sure prep and foam. Applied heel off-loading boots as well and son educated as he was in room as to the wound care and orders that will be placed as well as off -loading boots. He is in agreement with care at this time. CNA's (certified nurse aide) educated on use of heel off-loading boots as well. Will continue to monitor. On 2/7/22 a registered dietician documented: Pressure area to L (left) heel suspected DTI (deep tissue injury) and R (right) heel pressure injury stage 1 (one) were identified. RD (registered dietician) educated family that Boost supplement contains additional kcal/protein/vitamine C/zinc that will promote wound healing. RD also rec'd (requested) to add Juven (nutritional supplement) as this is specifically designed to promote wound healing. Son and dtr (daughter) have no further food/nutrition questions at this time. RD to cont(inue) to monitor. On 2/10/22 PTWCC documented: Weekly wound care assessment complete. B (bilateral) heels cleansed, measured and dressed. R (right) heel stage I (one) pressure injury is resolved. Slight blanching redness noted. Recommend continued use of sure prep and foam Q (every) day for protection. L (left) heel DTI (deep tissue injury) remains intact at this time. Area remains with deep purple/black discoloration but not eschar. Appears to be improving as no longer boggy. This may be able to resolve without skin opening. Patient report no pain with palpation. Completed dressing change with sure prep and foam and reapplied offloading boots. Will continue to monitor. V. Interviews The corporate nurse consultant (CNC) and physical therapist (PTWCC) were interviewed on 3/9/22 at 9:02 a.m. The PTWCC stated that she was wound certified and she currently worked in conjunction with the wound care physician to provide the treatment to the pressure wounds in the facility. The PTWCC stated she was notified of the concern with Resident #2 heels on 2/7/22 after the resident ' s family and physician had had noticed an open area to one heel, which she staged as a stage one pressure injury and a discoloration and what appeared to be a deep tissue injury (DTI) on the other heel. The PTWCC stated the treatment was started immediately on both heels. She said the stage one was treated with Sureprep (protective film over the wound bed) and a foam dressing. For the DTI the PTWCC initiated off-loading. The PTWCC stated the stage one pressure injury to the heel had healed by the time she reassessed the wounds on 2/10/22, and the DTI had also improved. The PTWCC said the resident was discharged home on 2/10/22, so no additional treatments were provided. The CNC said upon admission the resident was not identified as a high risk for pressure injuries, although there should have been interventions in place, such as off-loading her heels and protective boots when the resident was in bed, due to the resident ' s hip fracture and decreased ability to move.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection, including COVID-19. Specifically, the facility failed to: -Ensure staff and visitors wore the appropriate personal protective equipment (PPE) and performed appropriate hand hygiene when entering transmission-based precaution (TBP) rooms; -Ensure residents were offered hand hygiene before meals; -Ensure staff performed handwashing; -Ensure equipment was disinfected between residents; and, -Ensure housekeeping used chemicals correctly. Findings include: I. Facility policy and procedures A. The Infection Prevention, Control, and Immunizations policy, last revised 2/8/21, was provided by the nursing home administrator via email on 1/17/22 at 3:37 p.m. It read in pertinent part, Staff will use standard precautions (hand hygiene and appropriate PPE equipment). Staff will follow appropriate hand hygiene practice. PPE equipment to be worn for contact with blood, body fluids, [MEDICATION(S)] membranes, or non-intact skin. Appropriate PPE to be worn for infections/ illnesses. Staff will implement appropriate TBP. The facility will follow the Centers for Disease Control (CDC) Guidelines and recommendations. B. The PPE During the COVID-19 Pandemic policy, last revised 5/1/21, was provided by the nursing home administrator (NHA) via email on 1/17/22 at 3:37 p.m. It read in pertinent part, Gloves: Perform hand hygiene, then put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns:· Don gown upon entry into the patient room. Doff gown prior to exit and dispose of gown inside of patient room. Masks: Masks may be worn continuously until visibly soiled or damaged throughout shift. N95/KN95 respirator masks: Staff that has the potential to come into contact with patients on quarantine or transmission-based precautions will wear an N95 or KN95 mask. Eye Protection: Eye protection should be cleaned when a staff member can not visibly see through. Cleaning must be done outside of patient care areas. Eye protection will be worn in quarantine rooms. If a county's two week positivity rate is greater than 10%, eye protection will be worn universally. II. Failure to ensure staff and visitors wore the appropriate PPE and performed appropriate hand hygiene when entering TBP rooms A. Professional reference The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 9/10/21), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, HCP who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. B. PPE use A visitor was observed on 1/17/22 at 4:18 p.m.to enter resident room [ROOM NUMBER] which was a COVID-19 positive room. She wore a surgical mask and no other PPE. There was a stop sign on the resident's door. She stopped, looked at the stop sign on the door which explained what PPE to wear to enter (gown, gloves, N95 and a face shield or goggles) but she entered the room without donning PPE other than the face mask, entered the room and sat next to the resident. -On 1/18/22 at 1:32 p.m. the same visitor went into resident room [ROOM NUMBER] wearing only a surgical mask. -On 1/19/22 at 4:04 p.m. the same visitor was going to walk into resident room [ROOM NUMBER]. She was interviewed to see what education she was given from the facility on PPE use and the signs on the resident's doors. She was told to wear a face shield. She said there was no sign on room [ROOM NUMBER] door that said stop, see nurse so she went into the room. She did see the other stop sign on the door but did not know what that meant and was not concerned because she had on a face mask. The restorative aide (RA) was observed on 1/19/22 at 9:05 a.m. entering resident room [ROOM NUMBER], which was a COVID-19 positive room on isolation precautions. She wore an N95 mask and face shield. She delivered a food tray to the resident, touching items around the bedside table to make room for the food tray. She was interviewed immediately after the observation when she left the room. She said the stop sign was a reminder to wear full PPE, which included a gown, gloves, mask and face shield when entering an isolation room. She said she forgot to put on a gown and gloves when she entered the room. III. Incontinent care CNA #5 was observed on 1/19/22 at 11:30 a.m. assisting Resident #40 with incontinent care. After providing incontinence care, she did not perform hand hygiene before she put on the clean brief on the resident with the same gloves. She left the room to get a clean sheet, came back and covered the resident with the sheet. She used the same gloved hands to assist the resident with water, holding her cup for her and she opened a piece of candy and put the candy in the resident's hand. She failed to change gloves after incontinent care and perform hand hygiene. Cross-reference F677 assistance with activities of daily living (ADLs). Interviews The activity director (AD) was interviewed on 1/19/22 at 4:08 p.m. She said she was the receptionist at times and screened visitors. She said she made sure they had on an N95 mask before they went upstairs to the resident rooms. She said the nurses upstairs educated the visitors on what PPE to wear in each room. Licensed practical nurse (LPN) #3 was interviewed on 1/19/22 at 4:10 p.m. She said visitors read the signs posted on the resident rooms that were on isolation precautions to see the nurse and they were then educated on what PPE to wear in that room. She said the front desk receptionist educated the visitors when they signed into the building. LPN #3 immediately after the interview, went and spoke with the visitor in room [ROOM NUMBER]. IV. Failure to ensure residents were offered hand hygiene before meals A. Professional reference The CDC Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes (updated 9/10/21), retrieved on 1/31/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, read in pertinent part, Educate residents and families through educational sessions and written materials on topics, including information about [CONDITION(S)]-CoV-2, actions the facility is taking to protect them and their loved ones from [CONDITION(S)]-CoV-2, and actions they should take to protect themselves and others in the facility, emphasizing when they should wear source control, physically distance, and perform hand hygiene. B. Observations On 1/17/22 at 12:21 p.m. meal trays were passed to residents without offering resident's hand hygiene. Observations were as follows: Certified nurse aide (CNA) #1 was observed to deliver a meal tray to the resident in room [ROOM NUMBER]. The resident was not offered hand hygiene. The CNA failed to sanitize her hands prior to entering the room or after exiting the room. CNA #12 was observed to deliver a meal tray to room [ROOM NUMBER] the resident was not offered hand hygiene. The same CNA was observed to deliver a meal tray to room [ROOM NUMBER] which was an isolation room. She left the door cracked for observation. No hand hygiene was offered to the resident. CNA #1 was observed to deliver a meal tray to room [ROOM NUMBER]. The resident was not offered hand hygiene. CNA #12 was observed to deliver a meal tray to room [ROOM NUMBER] which was an isolation room with a large window facing the nurses station. There was no resident hand hygiene offered. 1/19/22 beginning at 12:17 p.m. CNA #12 delivered a tray to room [ROOM NUMBER]. The resident was not offered hand hygiene. She then delivered a tray to room [ROOM NUMBER] she did not offer the resident hand hygiene. The same CNA entered room [ROOM NUMBER] without sanitizing her hands. The resident was not offered hand hygiene. CNA #12 entered room [ROOM NUMBER]. The resident was not offered hand hygiene. C. Interview The nursing administer (NA) was interviewed on 1/20/22 at 3:36 p.m. The NA who was the interim infection preventionist said, the staff were to use hand sanitizer gel or wash their hands between cares. She said they should gel in and gel out of the rooms. The NA said residents needed to be offered hand hygiene with wipes. She said the staff had been trained on the importance of hand washing. V. Cleaning of resident rooms A. Record review The 730 disinfectant directions read, spray surface until thoroughly wet, allow to remain wet for one minute for [CONDITION(S)]-CoV-2, the virus that causes COVID-19. The 320 disinfectant cleaner was a bathroom disinfectant, cleaner and deodorant with a pleasant mint scent directions read, Allow treated surfaces to remain wet for 10 minutes. B. Observations On 1/19/22 at 10:39 a.m. the housekeeper supervisor (HSKS) entered the resident room. The HSKS entered the resident's bathroom and sprayed the 730 disinfectant spray on the toilet, touching the toilet seat while spraying the disinfectant, then sprayed the sink, and the half of the bathroom counter. The bathroom counter was not saturated with the 730 disinfectant as the directions instructed. The HSKS did not remove resident soap bottles from the right side of the counter and did not spray that part of the counter with disinfectant spray. The HSKS then proceeded to enter the room and cleaned the rest of the room. She did not change her gloves after touching the toilet seat and continued to clean the bathroom and resident room. The HSKS left the resident's bathroom and began gathering trash from the trash receptacles in the resident's room. At 10:41 a.m., she wiped the inside of the sink, then wiped the counter with the same cloth. The HSKS wiped the toilet seat and then the rest of the toilet and used a toilet brush from her cart to scrub the toilet bowl and placed the toilet brush in a plastic bag to return it to her cart. The HSKS did not change her gloves. She proceeded to sweep the floor using the same contaminated gloves. The HSKS did not clean any door handles. The HSKS left the resident room and threw the mop head and her gloves in the trash receptacle on the housekeeping cart. The HSKS did not sanitize her hands. On 1/19/22 at 10:51 a.m. the housekeeper ( HSK) sprayed a few sprays onto the cleaning cloth with the 730 disinfectant. The cloth was not visibly wet as it was sprayed on a dry cloth. She then proceeded to wipe the door handles of the resident room when entering the room. The HSK sprayed the desk area in the resident room and the tray table wiping the disinfectant off immediately. She wiped the door handles to the bathroom when she entered the bathroom and sprayed the 320 disinfectant in the sink and on the bathroom counter wiping the disinfectant off immediately. She then sprayed the toilet riser, the toilet and into the toilet bowl. She wiped the disinfectant off immediately. The HSK returned to the housekeeping cart and changed gloves. She did not sanitize her hands after removing the dirty gloves. The HSK took the broom from the cart and swept the floor of the resident room and returned the broom to the cart. She took the mop from the cart and the 730 disinfectant. The HSK sprayed the floors with the disinfectant and immediately mopped the floor. The floor dried immediately and the HSK returned to the housekeeping cart. C. Interviews The housekeeper supervisor (HSKS) was interviewed on 1/19/22 at 10:39 a.m. The HSKS said that the only disinfectant cleaner being used currently was the 730 disinfectant spray. The HSKS stated that the dwell time for the 730 disinfectant spray was five minutes. The HSK was interviewed on 1/19/22 at 11:00 a.m. The HSK said that the 730 disinfectant was to be used to clean everywhere except the bathroom. She said the dwell time for that disinfectant was two to three minutes. The HSK said that the bathroom cleaner was the 320 disinfectant and was unsure of the dwell time for that cleaner. The HSK said that she normally sanitized her hands between glove changes but forgot. The maintenance director (MTCE) was interviewed on 1/20/22 at 12:18 p.m. The MTCE who supervised the housekeeping department said he had been made aware that housekeeping staff were not donning proper PPE for isolation rooms and that he had discussed the isolation protocol with staff today. He said that the housekeeping staff had not received training from him before today, but they did receive infection control training from the director of nursing (DON) prior. The MTCE stated that housekeeping staff should carry alcohol based hand sanitizer with them and use it between tasks and between changing gloves. He said the bathroom should be cleaned first with one set of gloves then hand rub with hand sanitizer and then don gloves. The MTCE said the dwell time for the 730 disinfectant was one minute and surfaces were to remain saturated for one minutes prior to wiping clean. He said the dwell time for the 320 disinfectant was ten minutes and was only to be used in the toilet bowl. The MTCE said that there should be a toilet brush assigned to every room, the broom handle and mop handle should be disinfected between each use and the spray bottles should be wiped down between each use. V. Cleaning equipment A. Facility policy The policy and procedure titled Medical devices/ equipment - disinfection, dated 3/27/2020, revised on 2/8/21, read in pertinent part, The Centers will follow CDC (Centers for disease control and prevention) guidelines for disinfection of medical devices/ equipment . All non - dedicated, non-disposable medical equipment used for patient care is cleaned and disinfected with EPA (environmental protection agency) approved product/CDC guidelines & recommendations. B. Observations On 1/18/22 at 1:30 p.m., the vital sign machine was taken into room [ROOM NUMBER]. The vital machine was used to take vitals on the resident. The equipment was not sanitized prior to it being returned to the storage area to be used for next resident. On 1/18/22 at 3:08 p.m. facility equipment was taken from room to room without being sanitized between residents. Observations were as follows: CNA #11 took the vital sign cart from room [ROOM NUMBER] to room [ROOM NUMBER] without sanitizing between residents. The same CNA then took the same equipment to #229 to obtain that resident's vital signs. The equipment was not observed being sanitized after use in room [ROOM NUMBER]. The resident in room [ROOM NUMBER] was on isolation. C. Interview The nursing administer (NA) was interviewed on 1/20/22 at 3:36 p.m. The NA who was the interim infection preventionist said the equipment needed to be cleaned with bleach wipes in between each resident.

Based on observations, record review and interviews, the facility failed to ensure for one (#1) of three residents reviewed for pressure injuries received care consistent with professional standards of practice. The facility failed to take steps to prevent a stage 4 facility acquired pressure injury on the coccyx for Resident #1 leading to hospitalization and surgery. Resident #1 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the facility identified the skin status to include redness to coccyx (a small triangular bone at the base of the spinal column). The resident did not have a pressure injury at the time of admission. Record review and interview revealed the facility failed to timely and adequately respond to skin breakdown. In the first three days of his admission, Resident #1's coccyx was identified as having redness. On 5/18/21 the facility documented the coccyx was blanchable. On 5/28/21 the area on the coccyx was open and a dressing was obtained and applied. On 5/31/21 the area was identified as a moisture associated skin damage (MASD) with measurements of 7.3 cm X 8.2 cm. At this time the wound care certified (WCC) and physical therapist (PT) completed an assessment that included identifying the coccyx area as a MASD caused from multiple loose stools. The WCC stopped the previous dressing and started the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 6/3/21 the coccyx area measurements were smaller measuring 5.3 cm X 6.1 cm. The WCC included in her progress note to continue the Z-guard treatment. She also included in the progress note that she would be out of state and nursing staff were to resume the plan of care until the WCC returned. From 6/4/21 until 6/8/21 the daily skilled notes documented coccyx MASD, barrier cream applied. On 6/8/21 the area was identified as open, and a risk assessment form was completed. The risk assessment form described the coccyx area as wound at coccyx covering intergluteal cleft and bilateral buttock. Wound bed with 75% black eschar, 20% yellow slough, and 5% granulation. Wound edges are irregular. Periwound (around the wound) is noted blanchable redness. The area was not measured on 6/8/21. On 6/9/21 the wound measured 10.2 cm X 8.4 cm with 60% black eschar, 30% yellow slough, and 10% epithelial tissue; margins are irregular, blanchable redness noted to the periwound. A new dressing was ordered on 6/9/21, that included, cleanse site with wound cleanser and pat dry; apply sureprep to periwound for protection, apply [MEDICATION(S)] to necrotic tissue and yellow slough cover with foam dressing every day shift every other day. On 6/10/21 the registered dietician (RD) was notified the resident had an unstageable pressure ulcer. The RD ordered a dietary supplement. On 6/10/21 the nursing home administrator (NHA) called and requested a visit by a wound care specialist. On 6/12/21 the wound care physician (WCP) arrived and provided a debridement of the area that lasted two hours long. On 6/13/21 the resident was transferred to the emergency department due to an infection in the wound site. Record review also revealed there were no measurements or changes noted to the coccyx area between 6/3/21 until 6/8/21 when the wound went from 5.3 cm X 6.1 cm X 0 to 10.2 cm X 8.4 cm with 60% black eschar, 30% yellow slough, and 10% epithelial tissue. During that time there were no new interventions or re-evaluations of the interventions to prevent a facility acquired stage 4 pressure ulcer from causing hospitalization and subsequent surgery. The facility's failure to monitor and implement interventions for Resident #1's pressure injuries and known risks for pressure injuries, and failure to comprehensively address known barriers to prevention and healing thereafter, created serious harm resulting in Resident #1's hospitalization . I. Immediate jeopardy A. Findings of immediate jeopardy On 7/21/21 at 4:07 p.m., it was identified that the facility failed to prevent pressure injury development for Resident #1. In the five weeks of his stay, Resident #1 started with redness to his buttocks to an infected stage 4 pressure ulcer requiring hospitalization and subsequent surgeries. When the WCC went out of state, the coccyx area declined in five days to almost double the size and was unstageable. When the wound was documented on 6/8/21 there were no measurements obtained until the following day. No new interventions were implemented between 6/3/21 to 6/8/21. The resident admitted to the facility with a reddened area to the coccyx to an infected and necrotic stage 4 pressure ulcer requiring hospitalization and surgery. B. Facility plan to remove immediate jeopardy On 7/21/21 at 5:52 p.m., the facility submitted a letter to remove the immediate jeopardy, The plan read: The facility wound care specialist conducted a skin sweep on all patients in the center completed on 6/24/21. No new issues were identified. The wound care specialist will complete weekly rounds on all patients. The spreadsheet will be updated weekly and wounds/skin conditions will be reviewed weekly in the skin and weight meeting by the interdisciplinary team (IDT). All nurses will receive education that if a skin condition is identified, a Situation, Background, Assessment, and Recommendation (SBAR) must be completed, a risk management must be entered, appropriate notifications must be made, it will be placed on the 24 hour report, the physician will be notified, treatment orders will be obtained, preventative interventions will be implemented (i.e. heel floating, appropriate mattress, etc.). This education will begin on 7/21/21 during the night shift and will continue until all nurses have received education by the director of nursing (DON)/designee. All pressure ulcers will have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If a wound is identified, the DON will be immediately contacted via phone as the point person. The DON will then verify the pressure policy was followed and ensure that the care plan is updated/reviewed/revised and reflects the interventions implemented. The DON will then ensure appropriate prevention equipment has been implemented or ordered. All pressure ulcers will be followed by the IDT (DON, WCC, Asst. DON, RD, director of rehabilitation, and social services director) on a weekly basis. The wound orders will be reviewed for completeness and implementation on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON will be assigned to complete wound care duties in the absence of the wound care specialist. The ADON will be trained on the task required in the wound care specialists absence by 7/26/21. Any resident with a Braden score of 12 or below, identified as high risk, will have preventative interventions in place. The assigned nurse will be completing the Braden scale upon admission, and weekly thereafter until discharge. If the assigned nurse has concerns, they will put an intervention in place and notify the physician. The DON/designee will ensure the Braden was completed and accurate. The DON/designess will ensure required and follow-up as necessary that appropriate interventions were implemented and orders are in place. Upon hire and during facility orientation, the ADON/designee will train newly nurses on the procedures for pressure ulcers. Upon external nurses (due to agency use) working at the facility, schedulers will notify ADON/designee so education can be completed. If the ADON is not present, the DON will be responsible for the education. Direct care staff receive education on what to do when changes of skin condition occur and implementing certified nurse aide (CNA) interventions such as repositioning. The DON/designee will be responsible for conducting the training, which will immediately begin on 7/21/21 during the 6:00 p.m. to 6:00 a.m. shift. C. Removal if immediate jeopardy On 7/21/21 at 6:12 p.m., the nursing home administrator (NHA) was informed the immediate jeopardy had been lifted at 6:04 p.m., based on the facility's implementation of the above plan. However, the deficient practice remained at G level, actual harm for Resident #1. II. Professional reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. III. Facility policy and procedures Review of the Skin Evaluation policy, revised 2/8/21, provided by the NHA on 7/20/21 at 11:28 a.m. read in part, Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. In addition the shall describe and document the following: -Full evaluation of skin to include pressure sore including description of the wound (if any). -Skin Evaluation will be scheduled weekly. -Nurse to follow treatment orders as prescribed, if no treatment order was given nurse to notify the physician. The Physician will assist identifying factors contributing or predisposing patients to skin breakdown. For example: medical comorbidities such as diabetes or CHF (congestive heart failure), overall medical instability, cancer or [CONDITION(S)] causing a catabolic state, and macerated or friable skin. If any new skin conditions are found during the patient's stay (bruise, abrasion, skin tear, pressure, etc) a risk management will be completed. MD (medical doctor) and family will be notified. New orders and notifications will be documented. Review of the Pressure Ulcer policy, revised 2/8/21, provided by the NHA on 7/20/21 at 11:28 a.m. read in part, Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin. In addition the shall describe and document the following -Full evaluation of pressure sore including description of the wound -Pain evaluation -Patients mobility status -Current treatments, if applicable -MD and family notification The Physician will assist identifying factors contributing or predisposing patients to skin breakdown. For example: medical comorbidities such as diabetes or CHF, overall medical instability, cancer or [CONDITION(S)] causing a catabolic state, and macerated or friable skin. The Physician will help clarify relevant medical issues: For example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing etc. The Physician will authorize pertinent orders related to wound treatments -Although poor nutritional status is associated with increased risk of pressure ulcer development, no specific nutritional have been proven conclusively to prevent of heal pressure ulcers. Nutritional supplement should be based on realistic appraisal of need to and identification of medical conditions and factors that affect appetite, weight and overall nutritional balance. The Physician will assist the staff with reviewing current orders when wounds are not healing as anticipated or new wounds develop despite existing interventions. -Healing may be delayed or may not occur, or additional ulcers may occur because of the other factors, which cannot be modified. -Wounds reflect the individuals overall medical instability: an existing wound is unlikely to improve significantly, additional wounds are likely to occur preventive efforts. IV. Resident #1 A. Resident status Resident #1, age 81, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission physician documentation, dated 2/11/21, revealed in part, Skin: warm and dry, no suspicious [CONDITION(S)] .C4-5 spinal cord injury - patient wheelchair bound at this time .[CONDITION(S)]- as per above .Depression-severe at this time. Patient with severe trauma and change in overall status. Is now a new quadriplegic. The 5/21/21 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident was identified as at risk for wound development, however the MDS also identified the resident did not have any wounds, open areas nor MASD. B. Record review The care plan, initiated 5/15/21 and revised on 5/31/21, identified a potential for skin breakdown related to recent hospitalization due to acute blood loss [CONDITION(S)] from penile discharge-was transfused at the hospital documented with bacteremia on 4 antibiotic ending 5/30/21. Resident #1 has a medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: -Air mattress to bed per facility guidelines (5/15/21). -Apply moisturizer to my skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing (5/15/21). -Braden scale every week per protocol, and skin evaluation as ordered and as needed (5/15/21). -Monitor lab values as ordered (5/15/21). -Monitor/reminding/assist to turn/reposition frequently, as needed or requested (5/15/21). -Notify physician of any signs and symptoms of infections (5/15/21). -Physical Therapy and Occupational as ordered to increase independence with mobility (5/15/21). -Pressure relieving Mattress per facility protocol and as ordered (5/15/21). -Skin Treatment per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] -Toileting will be provided as needed (5/15/21). The 5/15/21 comprehensive admission data identified the coccyx was red. The baseline care plan developed on 5/15/21, identified a potential for skin breakdown. Interventions included, the resident's skin issue will show signs of healing and remain free from further breakdown and infection over the next 90 days. The baseline care plan developed on 5/15/21, identified a goal of the resident's skin will remain intact over the next 90 days. Interventions included: -Air mattress to bed per facility guidelines -Skin Treatment per physician order. -Toileting will be provided as needed -Apply moisturizer to my skin. Do not massage over bony prominences and use mild cleansers for peri-care/washing -Braden scale every week per protocol, and skin evaluation as ordered and as needed -Dressing changes per physician order -Encourage proper nutrition and hydration as needed -Monitor lab values as ordered. -Monitor/reminding/assist to turn/reposition frequently, as needed or requested. -Notify physician of any signs and symptoms of infections -Physical Therapy and Occupational as ordered to increase independence with mobility. -Pressure relieving Mattress per facility protocol and as ordered. The 5/16/21 skin evaluation failed to identify the redness on the coccyx. The 5/16/21 daily skilled nursing note documented redness to the coccyx. The 5/17/21 daily skilled nursing note documented the coccyx was red and blanchable. -There was not a daily skilled note completed for 5/18/21. The 5/19/21 daily skilled nursing note documented the coccyx had blanchable redness. The 5/20/21 daily skilled nursing note documented the coccyx was red and the skin was blanchable. The 5/21/21 daily skilled nursing note documented the coccyx was red and the skin was blanchable. The 5/21/21 skin evaluation failed to identify the redness on the coccyx. The Braden scale completed on 5/21/21 scored Resident #1 at a 16 out of 23 identifying him as a low risk. The 5/22/21 daily skilled nurses note noted the coccyx had blanchable redness. The 5/23/21 daily skilled nursing note failed to identify the redness on the coccyx. The 5/24/21 daily skilled nursing note failed to identify the redness on the coccyx. The 5/25/21 daily skilled nursing note failed to identify the redness on the coccyx. The 5/26/21 daily skilled nursing note documented the coccyx was blanchable with redness. -There was not a daily skilled note completed for 5/27/21. The 5/28/21 daily skilled nursing note documented the coccyx was red and had open areas. A foam dressing was applied. An order was received on 5/28/21 for barrier cream and dressing two times a day. The WCC was to evaluate. The 5/29/21 daily skilled nursing note documented the coccyx was red with open areas. A foam dressing was applied. The 5/31/21 daily skilled nursing note documented the coccyx was red with open areas. A foam dressing was applied. The 5/31/21 wound evaluation completed by the WCC measured the coccyx area at 7.3 cm X 8.2 cm. The WCC classified the wound as MASD. The 5/31/21 skin/wound note noted, Initial wound care assessment completed as this clinician was asked this morning (AM). to assess peri anal area for breakdown. Patient has been having multiple loose stools a day and this has led to MASD and coccyx and both gluteal cleft skin breakdown. Area cleansed, measured and dressed after performing hygiene for loose stool that was saturated on skin and under the foam dressing that was in place. Skin is sloughing off but is superficial with 100% epithelial tissue present. There was scant serous sanguineous drainage and surprisingly no pain noted by patient, as he was asked multiple times. Surrounding skin sloughing off. Educated CNA (certified nurse aide) and nursing staff to not put a dressing on as the bowel is just getting under the dressing and being held in that place and causing more damage to skin. Educated on use of Z-guard, to wipe only top layer off and liberally apply new layer . Patient is on IV ABX for UTI which may be contributing to skin breakdown as well. Will continue to monitor. On 5/31/21 a new treatment was ordered: -Lightly remove only the top layer of Z-guard from the perianal skin/coccyx/gluteal cleft with a wipe. Once cleansed properly, apply a thick layer of Z-guard. Complete four times a day (QID) and as needed (PRN). The 6/1/21 daily skilled nursing note documented the coccyx was MASD with wound care following the resident. The note also included the treatment was in place to be checked four times a day. The 6/2/21 daily skilled nursing note documented the coccyx was MASD with wound care following the resident. The note also included the treatment was in place to be checked four times a day. The 6/2/21 skin/wound note documented, Assessed both buttocks, perianal/coccyx area due to MASD. Appears to be beginning to resolve as surrounding skin appears firmer and with increased tensile strength. Patient continues to report no pain. Noted that loose stool has decreased. Continue with Z-guard at this time and continue to monitor. The care plan, initiated 6/2/21, identified a potential risk for pressure ulcer development related to decreased mobility. Interventions included: -Barrier cream as ordered/as needed (6/2/21). -Frequent repositioning (6/2/21). -Pressure Reduction Mattress (6/2/21). -Pressure Reduction Wheelchair Cushion (6/2/21). The 6/3/21 daily skilled nursing note documented the coccyx was MASD with wound care following the resident. The note also included the treatment was in place to be checked four times a day. The 6/3/21 wound care note measured the coccyx area at 5.3 cm X 5.1 cm. The WCC classified the wound as MASD. The 6/3/21 skin/wound note documented, Weekly wound care assessment complete. MASD on coccyx/perianal area cleansed, measured and Z-guard liberally applied. Wound bed is much smaller and the surrounding skin is improving with increased strength and adherence. Unable to assess full depth due to slough and the layers of Z-guard currently on the wound bed. However, decreased redness. Wound with minimal serous sanguineous purulent drainage. Patient reports no pain. There has been a decrease in amount of loose bowel incontinence which is contributing to wound resolving. Patient reports no pain. Educated CNA and nursing staff that wound does appear to look bad however, due to Z-guard and skin tensile strength improving, the wound is healing. This clinician will be going out of state today, therefore nursing staff to resume plan of care (POC) until this clinician returns. The 6/4/21 daily skilled nursing note documented the coccyx barrier cream was applied. The 6/4/21 skin evaluation documented moisture related skin damage (MRSD) to the coccyx. The barrier cream was applied. The Braden scale completed on 6/4/21 scored Resident #1 at a 14 identifying him as a moderate risk. The 6/5/21 skin evaluation documented moisture related skin damage (MRSD) to the coccyx. The barrier cream was applied. The 6/6/21 skin evaluation documented moisture related skin damage (MRSD) to the coccyx. The barrier cream was applied. The 6/7/21 skin evaluation documented the Z-guard was applied to the buttocks and groin area, and redness was noted. The 6/8/21 daily skilled nursing note documented open area to coccyx. -There were no documented measurements of the coccyx open area. The risk management form dated 6/8/21 described the coccyx area as wound at coccyx covering intergluteal cleft and bilateral buttock. Wound bed with 75% black eschar, 20% yellow slough, and 5% granulation. Wound edges are irregular. Periwound is noted blanchable redness. -The form did not include any measurements of the coccyx. On 6/8/21 a new treatment order was received: -wound care to coccyx/sacrum/bilateral buttock-cleanse site with wound cleanser and pat dry; apply sureprep to periwound for protection, apply [MEDICATION(S)] to necrotic tissue and yellow slough. Cover with foam dressing. Every day shift every three days and as needed. On 6/8/21 a new air mattress was started. -The care plan was not updated to reflect revisions of interventions and/or new interventions started after the enlarged coccyx wound area was discovered The 6/9/21 daily skilled nursing note documented a coccyx/bilateral buttock unstageable pressure (injury), wound measured 10.2 cm X 8.4 cm with 60% black eschar, 30% yellow slough, and 10% epithelial tissue. The margins were irregular, and blanchable redness noted to the periwound. The 6/10/21 daily skilled nursing note documented a large open area to coccyx with black/yellow eschar and large amount of drainage. Silver antimicrobial dressings applied and the patient was lying on his side, reposition every two hours. On 6/10/21 new orders were received for the coccyx treatment: -wound care to coccyx/sacrum/bilat buttock-cleanse site with wound cleanser and pat dry; apply sureprep to periwound for protection, apply [MEDICATION(S)] to necrotic tissue and yellow slough, cover with foam dressing/[MEDICATION(S)] to secure. Every shift for wound care change dressings to bottom two times a day. -keep patient off back/bottom while in bed, roll side to side every two hours. Every shift for breakdown. -Juven two times a day for wound healing. The 6/10/21 administrative note documented, Call placed to (wound care specialists) to schedule wound care visit. Received notification the earliest visit available is Saturday at 10:00 a.m. The 6/11/21 daily skilled nursing note documented a large open area to coccyx with black/yellow eschar and large amount of drainage. Silver antimicrobial dressings applied and the patient was lying on his side, reposition every two hours. The Braden scale completed on 6/11/21 scored Resident #1 at a 14 identifying him as a moderate risk. The 6/11/21 skin evaluation noted skin breakdown to coccyx and buttocks, with the dressing in place. On 6/11/21 a new order for a [MEDICATION(S)] was received. Give one capsule by mouth two times a day. On 6/11/21 a new antibiotics order was received, [MEDICATION(S)] 250 mg by mouth every eight hours for infection. The 6/12/21 daily skilled nursing note documented a large open area to coccyx with black/yellow eschar and large amount of drainage. A two hour consultation with the wound doctor. Updated orders, lying on side, and reposition every two hours. The daily nursing note dated 6/12/21 at 6:19 p.m. documented, Spent two hours with wound care doctor on [MEDICATION(S)] the wound, entered orders into the system, and obtained requested labs, notified DON of the situation, called the on call to inform them of the wound care doctor's recommendation to have antibiotic (ABX) coverage for presumed pseudomonas. (The on-call) Nurse Practitioner (NP) said she would not prescribe anything as it should have been done by wound care. Asked for pain medication post debridement for patient and was only given 5 mg of oxy (oxycodone, pain medication) for 24 hours as she does not feel comfortable prescribing more without seeing the patient. The daily nursing note dated 6/13/21 at 12:25 p.m. documented, Wound dressing change performed. Patient pre-medicated and during the procedure rated pain 10/10. Updated photograph of wound sent to wound care doctor. The lack of effective antibiotics and pain control were brought to the attention of the DON who agreed with transporting patient to the emergency room (ER) for further evaluation and treatment. Message left with on call physician answering service. Patient's son and daughter-in-law were notified and it was elected by them to have the patient sent to (hospital). (Ambulance service) notified for transport, report called to (hospital) ER nurse Patient transported via stretcher with some personal belongings to ambulance and then to (hospital). The etransfer note dated 6/13/21 identified the reason for transfer to the hospital was for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -The care plan was never updated/reviewed past 6/3/21 with interventions. C. Hospital records The hospital admission records from 6/13/21 documented: -This is an 81 y.o. (year old) male who originally reported to the emergency department with complaint of Wound Check. We have a vague history regarding the timing of the patient's sacral decubitus ulcer. The nursing facility potentially noticed a small ulcer approximately a week ago. It is not clear what care he received. In any event the patient arrives via EMS today for evaluation of a large sacral decubitus ulcer. He denies pain, no abdominal pain. He is not sure if he has had a fever. He is not currently complaining of back pain. -Skin: Warm and dry, no rashes, no petechiae. Large approximately 10 x 7 cm decubitus ulcer that appears stage 4, it is malodorous, there is no significant discharge. Appears necrotic. Mild to moderate surrounding [CONDITION(S)] to the skin. -Patient presents with a decubitus ulcer that has been ongoing for the past several weeks that is worsening. Reportedly they attempted to debride it yesterday. Patient denied any fevers, chills any significant bodily discomforts other than sacral pain. On exam patient does have a large 10 x 7 cm stage 4 decubitus ulcer, does smell malodorous, there is mild to moderate surrounding [CONDITION(S)], there is some central necrotic tissue as well .He was started on [MEDICATION(S)] and [MEDICATION(S)] for antibiotic coverage. I did discuss the case with the surgical service who agrees to consult with the patient for possible debridement. Discussed with the hospitalist team at (sister hospital) who will admit patient for further evaluation and treatment. Patient has remained stable throughout his ED course. Assessment and plan discussed with both patient and family members at bedside, they are in agreement and appreciative of his care. D. Interviews Licensed practical nurse (LPN) #1 was interviewed on 7/19/21 at 12:15 p.m. She said upon admission every resident was given a head to toe assessment. She said all findings were documented to prevent any delay of cares a resident might need. CNA #1 was interviewed on 7/19/21 at 2:05 p.m. He said skin checks were done each time any care was provided to each resident. He said if anything unusual was found, it was reported immediately to the medication nurse or the charge nurse. He said the facility provided education on turning and repositioning a couple of weeks ago. He said it was important to maintain good skin conditions for all the residents. RN #1 was interviewed on 7/19/21 at 2:18 p.m. She said if a new skin issue was reported, a risk assessment was completed and all parties are notified. She said after a through assessment was completed, the provider was notified and if new orders are given, they were entered into the system. She said changes in skin were also documented in the daily skilled nursing note. She said when a new admission arrived, she would complete a head to toe assessment and document anything discovered to have a complete record for the resident. The WCC was interviewed on 7/20/21 at 12:05 p.m. She said as the WCC she could conduct some debridement to wounds, measure the wound, decide on specific dressings/ointments, and apply the dressings. She said she would write the order and the NP or MD would sign it off. She said if a wound was worsening she would communicate with the provider or ask the nurse to call the provider. She said when Resident #1 was admitted she noted blanching on the coccyx area. She said Resid