Every finding on record at Village Care and Rehabilitation Center, The

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure glucometers were sanitized appropriately. Findings include: I. Professional reference The Centers for Disease Control and Prevention (CDC). Considerations for Blood Glucose Monitoring and Insulin Administration (2024), was retrieved on 12/18/24 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html#:~:text=Unsafe%20practices%20during%20assisted%20monitoring,for%20more%20than%20one%20person. It read in pertinent part, Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place. II. Manufacturer's guidelines According to the Arkray Assure Platinum manufacturer guidelines, revised 09/2024, retrieved on 12/18/24 from https://arkrayusa.com/diabetes-management/professional-healthcare-products/assure/assure-platinum/, The meter should be cleaned and disinfected after use on each resident. The cleaning procedure is needed to clean dirt, blood and other bodily fluids off the exterior of the meter before performing the disinfecting procedure. The disinfecting procedure is needed to prevent the transmission of bloodborne pathogens. The Super Sani-cloth wipe manufacturer's guidelines, updated 2021, was retrieved on 12/19/24 from https://pdihc.com/in-service/super-sani-cloth-instructions-for-use-ifu-sign/. It read in pertinent part, Unfold a clean wipe and thoroughly wet surface. Allow the treated surface to remain wet for two minutes. Let air dry. III. Observations On 12/17/24 at 10:58 a.m. during medication pass, licensed practical nurse (LPN) #1 retrieved the hallway's glucometer machine from the medication cart. She entered Resident #10's room to check his blood sugar. LPN #1 then left the resident's room and placed the glucometer on top of the medication cart without cleaning it. She continued with her medication pass for another resident and then placed the glucometer back in the medication cart drawer at 11:19 a.m. On 12/17/24 at 11:39 a.m. LPN #1 took the glucometer out of the medication cart drawer and put it on top of the cart. LPN #1 gathered the rest of the supplies needed and placed them on top of the glucometer. She then picked up the glucometer to go into Resident #208's room and check her blood sugar. - LPN #1 did not clean or sanitize the glucometer between residents. IV. Staff interviews LPN #1 was interviewed on 12/17/24 at 11:40 a.m. LPN #1 said the residents did not have their own glucometers. She said normally if she were to use the same glucometer on another resident, she would clean it in between residents with a Sani-cloth purple-top wipe. She said she forgot to clean the glucometer after using it. The nursing home administrator (NHA) and the interim assistant director of nursing (IADON) were interviewed together on 12/17/24 at 1:42 p.m. The IADON said there was one glucometer per hallway. She said one to three residents per hallway regularly used the glucometer. She said the staff were expected to wipe down the glucometer with an alcohol-based wipe in between residents. She said there was a drawer full of new glucometers and that each resident used to have their own. She was not sure why that policy changed. The NHA said the purple top Sani-cloth wipes or alcohol were used to clean the glucometers. The NHA said the glucometers should be cleaned and sanitized after each blood sugar check and then returned to the drawer. She said the proper way to clean the glucometers was to clean all sides of the glucometer, throw away the disposable items, throw the lancet (small, sharp needle used to prick the skin and obtain a blood sample) in the sharps container, then sanitize the glucometer using specific dwell times (how long the treatment surface must remain visibly wet for proper sanitation) depending on the wipe. She said the dwell times were posted near each nurse's station. The NHA said there were no residents in the facility with a transmittable blood-borne disease. She said she would ensure each resident had their own glucometer. The NHA said the nursing staff would be re-educated on expectations for glucometer cleaning. V. Facility follow-up On 12/18/24, all three medication carts were observed to have glucometers that were labeled with individual residents' names. Lists of cleaning supplies and their dwell times were posted on the wall across from each medication cart. The Sani-cloth purple top wipes were noted to require a two minute dwell time.

Based on record review and interviews, the facility failed to ensure two (#42 and #45) of two residents out of 29 sample residents were free of significant medication errors. Specifically, the facility failed to: -Ensure Resident #45 was administered his schizoaffective disorder medication per the physician orders; and, -Ensure Resident #42 was administered his diabetes medication per the physician orders. Findings include: I. Professional reference According to the Trihexyphenidyl dosing instructions, retrieved on 12/30/24 from https://www.goodrx.com/trihexyphenidyl/what-is#dosage, Trihexyphenidyl is an anticholinergic medication that blocks acetylcholine, a chemical that affects movement. It is used to help with tremors in adults with Parkinson's disease. It can also be used for movement-related side effects caused by other medications. Don't stop taking trihexyphenidyl unless instructed by your provider. Suddenly stopping the medication can lead to withdrawal symptoms, such as anxiety and worsening movement problems. The recommended dosage for trihexyphenidyl tablets and oral solution are the same. For movement problems, the daily dose ranges from five to 15 milligrams (mg) by mouth per day. II. Facility policy and procedure The Medication Error Reporting and Adverse Drug Reaction Prevention and Protection policy and procedure, revised January 2023, was received from the nursing home administrator (NHA) on 12/18/24 at 3:32 p.m. It documented in pertinent part, Medication errors and adverse drug reactions are assessed, documented, and reported as appropriate to the resident's attending physician and/or prescribers, the pharmaceutical services committee, the pharmacy and Food and Drug Administration Med (medication) Watch Program. In the event of a significant medication error or adverse drug reaction, immediate action is to be taken to protect the resident's safety and welfare. Actions include notifying the prescriber, monitoring the resident closely, describing the incident on shift change report to alert the staff of the need to monitor the resident and documenting an incident report which includes a factual description of the error or adverse reaction, name of prescriber and time notified, prescriber's subsequent orders and the resident's condition for 24 to 72 hours or as directed. III. Resident #45 A. Resident status Resident #45, age 69, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder (mental disorder that affects mood, thoughts and behavior), depression and muscle weakness. According to the 11/15/24 minimum data set (MDS) assessment Resident #45 was cognitively intact with a brief interview for mental status score of 13 out of 15. He required partial/moderate assistance with showering, dressing, and personal hygiene. He was independent with walking and transfers. B. Resident interview Resident #45 was interviewed on 12/16/24 at 11:15 a.m. Resident #45 said he was concerned about not getting some of his medications and not getting some medications on time. He said he missed some doses of trihexyphenidyl a few weeks ago but could not remember the exact date or how many doses he missed. He said he had a mental illness and needed to take all of his medications on time. C. Record review Review of Resident #45's December 2024 CPO revealed the following physician order: Trihexyphenidyl 2 mg tablet two times daily for schizoaffective disorder, administer one tablet orally, ordered 11/10/24. Trihexyphenidyl 2 mg tablet one time daily for schizoaffective disorder, administer two tablets orally, ordered 11/10/24. Review of Resident #45's November 2024 medication administration record (MAR) revealed the following: -On 11/18/24 Resident #45 did not receive trihexyphenidyl at 9:00 p.m.; -On 11/19/24 Resident #45 did not receive trihexyphenidyl at 9:00 a.m.; -On 11/19/24 Resident #45 did not receive trihexyphenidyl at 3:00 p.m.; and, -On 11/19/24 Resident #45 did not receive trihexyphenidyl at 9:00 p.m. A nursing progress note dated 11/19/24 at 12:32 a.m. revealed Resident #45 was noted to be out of trihexyphenidyl. The nurse called the pharmacy and the pharmacy confirmed the refill. The pharmacy said the medication would arrive on 11/19/24. The progress note documented that Resident #45 was pleasant and cooperative with no delusions or hallucinations reported. A nursing progress note dated 11/20/24 at 5:03 a.m. revealed Resident #45 continued to be out of trihexyphenidyl. It was documented that the pharmacy was called and confirmed the refill. A STAT (immediate) delivery was requested and the pharmacy confirmed it would be delivered before 8:00 a.m. on 11/20/24. It was documented that Resident #45 was pleasant and cooperative at baseline with no delusions or hallucinations reported. -The nursing staff failed to audit the cart and reorder the medication before the medication ran out. -The nursing staff failed to order the medication as STAT once they noticed it was missing. -There was no documentation that the resident's physician was notified after Resident #45 missed four doses of trihexyphenidyl. D. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 12/18/24 at 11:42 a.m. LPN #3 said it was the responsibility of all nurses to order medications once they were ready for refill. She said the night nurses audited the medication carts for expired medications and medications ready for refill. LPN #1 was interviewed on 12/18/24 at 11:53 a.m. LPN #1 said the medications came with a sticker on the package that had a date which indicated when they were ready for refill. She said it was the responsibility of the nurse on the cart to peel off the sticker and fax it into the pharmacy to get the medication refilled once it was available. She said there was another way to refill medications through the computer. She said if a medication was missing, she would look and see if it was in the emergency medications kit. LPN #1 said if the medication was not available in the emergency medications kit, she said she would request a STAT order refill from the pharmacy. She said the pharmacy might make overnight runs for STAT or hospice medications. She said if a medication was not available, she would also contact the NHA. The NHA and registered nurse (RN) #1 were interviewed together on 12/18/24 at 1:8 p.m. RN #1 said medications could be ordered a week in advance, prior to the medication running out. He said the order could either be faxed into the pharmacy or entered electronically through the charting system. He said if a medication was unavailable, it could be ordered STAT. The NHA said if a medication dose was missed, he would expect the nurse to notify the physician and monitor the resident for side effects, which could include increased agitation for missing trihexyphenidyl. He said Resident #45 might be more distressed from missing a medication because he was very aware of all his medications and anything missed could really throw him off his routine and make him more agitated. The NHA said there should be a progress note or medication administration note filled out by nursing any time a medication dose was not given. RN #1 said it was the expectation to order any medication as STAT once it was noticed the medication was out of stock. 31229 IV. Resident #42 A. Resident status Resident #42, age 76, was admitted on [DATE]. According to the December 2024 CPO, diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (a condition where multiple nerves outside the brain and spinal cord are damaged or malfunctioning simultaneously), traumatic hemorrhage of cerebrum (a collection of blood in the brain that occurs after a traumatic brain injury), and left side hemiplegia (a medical condition characterized by paralysis or weakness on one side of the body). According to the 9/29/24 MDS assessment, Resident #42 was cognitively intact with a BIMS score of 15 out of 15. He required set-up assistance with eating, supervision with oral hygiene, substantial/maximal assistance with toileting hygiene, shower/bath and upper and lower body dressing. He required substantial/maximal assistance with bed mobility and transfers. The MDS assessment documented the resident was prescribed and administered antidepressant, anticoagulant, antibiotic, opioid and hypoglycemic medications. B. Resident interview Resident #42 was interviewed on 12/16/24 at 1:15 p.m. Resident #42 said he was concerned about not getting his prescribed medication for diabetes mellitus. He said he had missed five days of metformin in December 2024. C. Record review Review of Resident #42's comprehensive care plan revealed there was no care plan focus related to the resident's diagnosis of diabetes mellitus or the prescribed medication metformin. Review of Resident #42's December 2024 CPO revealed the following physician order: Metformin ER 500 mg tablet, extended release 24 hour (two tablets/1000 mg), oral, two times daily, ordered 8/21/24. A review of Resident #42's December 2024 MAR revealed the following: -On 12/10/24 Resident #42 did not receive metformin at 8:00 a.m.; -On 12/10/24 Resident #42 did not receive metformin at 8:00 p.m.; -On 12/11/24 Resident #42 did not receive metformin at 8:00 p.m.; -On 12/12/24 Resident #42 did not receive metformin at 8:00 a.m,; -On 12/12/24 Resident #42 did not receive metformin at 8:00 p.m.; and, -On 12/13/24 Resident #42 did not receive metformin at 8:00 a.m. Nursing administration notes for the 12/10/24, 12/11/24, 12/12/24 and 12/13/24 missed doses of metformin documented the medication was not administered because the medication was not available. -The nursing staff failed to audit the cart and reorder the medication before the medication ran out. -The nursing staff failed to order the medication as STAT once they noticed it was missing. -There was no documentation that the resident's physician was notified after Resident #42 missed six doses of metformin. D. Staff interviews The MDS coordinator (MDSC) was interviewed on 12/18/24 at 9:56 a.m. The MDSC said she was not aware there was no care plan focus related to Resident #42's diagnosis of diabetes mellitus or his metformin medication. RN #1 was interviewed on 12/18/24 at 1:20 p.m. RN #1 said Resident #42's metformin was not ordered STAT. He said the medication was not delivered from the pharmacy for three days after it was ordered. He said metformin was not included in the emergency medications kit and he could not explain why a nurse documented on the December 2024 MAR that the resident's 8:00 a.m. dose of metformin was administered on 12/11/24. He said all registered and licensed nurses received additional training related to the medication ordering process on 12/17/24 (during the survey).

Based on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#32) of two residents reviewed for activities out of 29 sample residents. Specifically, the facility failed to invite Resident #32 to group activities and meet the socialization needs for the resident. Findings include: I. Resident #32 A. Resident status Resident #32, age 77, was admitted on [DATE]. According to the December 2024 computerized physician orders (CPO), diagnoses included pneumonia (lung infection), pulmonary emboli (blood clots in the lungs) and type 2 diabetes (high blood sugar). The 11/6/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. She required complete assistance with hygiene, showering and dressing. The 11/6/24 MDS assessment documented that all activities were not very important to Resident #32. It was documented that her language preference was Hmong. B. Observations During a continuous observation on 12/16/24, beginning at 9:15 a.m. and ending at 10:00 a.m., the following was observed: At 9:15 a.m. Resident #32 was lying in her bed with the door open. Her eyes were open and she was looking out into the hallway. At 9:45 a.m. a balloon toss activity was going on in the living room area of the unit. Resident #32 was not invited to attend the activity. At 9:50 a.m. two certified nursing aides (CNA) went into Resident #32's room and changed her brief. The CNAs did not take the resident to the balloon activity after changing her brief. During a continuous observation on 12/16/24, beginning at 12:45 p.m. and ending at 2:20 p.m., the following was observed: At 12:45 p.m. Resident #32 was lying in her bed. The resident's bedside table was not next to her. There was a translator device at the end of the bed. There was a stack of daily chronicles in English on a nightstand next to the bed, out of reach of the resident. There were no coloring supplies or other individualized activities observed in her room. At 1:30 p.m. there was a fitness activity going on in the living room of the unit. Resident #32 was not invited to attend the activity. At 2:15 p.m. bingo was going on in the living room of the unit. Resident #32 was not invited to attend the activity. During a continuous observation on 12/17/24, beginning at 9:15 a.m. and ending at 11:10 a.m., the following was observed: At 9:15 a.m. Resident #32 was lying in her bed. She was awake and talking in her preferred language (Hmong) with the door open. The NHA walked into Resident #32's room and asked her how she was doing. The NHA did not use the translator to talk with Resident #32. At 9:30 a.m. Resident #32 started to talk in Hmong. At 10:02 a.m. Resident #32 put her call light on. At 10:12 a.m., the NHA went into Resident #32's room. The NHA spoke to her in English and did not attempt to use the translator device that was in the room. At 10:45 a.m. there was a hymnal singing activity going on in the living room of the unit. Resident #32 was not invited to attend the activity. C. Resident interview Resident #32 was interviewed utilizing the resident's translator device on 12/16/24 at 12:47 p.m. Resident #32 said she would like to get up and live a normal life but she just laid in her bed all the time. D. Record review The activity care plan, updated 10/7/24, documented the goal for Resident #32 was that she had a significant language barrier but that she did not like television and did enjoy music. Interventions included the activity team supplying the resident with daily and monthly activity guides, seeking opportunities to engage in one-on-ones with music and approved snacks, finding opportunities to engage with the resident's representative to find out how the facility could accommodate the resident and having the activity team make attempts to get the resident out to social events with music. A progress note written by the social worker on 12/17/24 at 7:46 a.m. documented that the social worker reached out to Resident #32's representative for a check-in regarding the resident. They discussed translation and communication cards that were provided. The representative said Resident #32 would likely not use the communication cards. II. Staff interviews CNA #1 was interviewed on 12/18/24 at 12:20 p.m. CNA #1 said Resident #32 refused to get out of bed when they offered. She said she had not seen her participate in activities. CNA #1 said she had not really used the translator device or communication cards to communicate with Resident #32. She said Resident #32 did not refuse care. -However, observations during the survey revealed staff did not attempt to invite Resident #32 to the activities that were occurring (see observations above). The activities director (AD) was interviewed on 12/18/24 at 3:23 p.m. The AD said the process for inviting residents to activities included passing out the daily chronicle the evening before and highlighting some of the activities with the residents so they could plan for the next day. She said there was also a monthly activity calendar passed out at the beginning of each month. She said it was her expectation that every resident got invited to each activity unless they specified otherwise. She said she and the activity aides went around to each resident and invited them to the activity prior to the start of the activity. She said if the resident was sleeping or receiving care, they did not bother the resident. She said she needed to work on making accommodations for residents who spoke a primary language other than English. She said she was not sure what primary language Resident #32 spoke and she was unaware of the translator device in her room. The AD said she did not invite Resident #32 to activities because of the language barrier and because sometimes Resident #32 was sleeping. She said she offered coloring sheets to Resident #32 one time but the resident did not seem interested. She said she was not sure what Resident #32's activity preferences were. She said she did not have access to her care plan or activity assessment. She said she got to know the residents by talking with them as she passed out the daily chronicles. The director of resident life services (DRLS) was interviewed on 12/19/24 at 11:30 a.m. The DRLS said it was his responsibility to oversee the activity programming on the skilled nursing side and complete all resident activity assessments and care plans. He said the AD had access to the care plans and activity assessments through the resident charting system. He said Resident #32 liked to read through the daily chronicle, color and complete word searches. He said she did not understand English very well but she could shake her head for yes/no questions. The NHA was interviewed on 12/19/24 at 1:22 p.m. The NHA said it was her expectation that all residents were to be invited to activities they would enjoy. She said to communicate with residents whose primary language was not English, she would expect staff to communicate with the translator device or communication flashcards. -However, the NHA did not use the translator device in Resident #32's room to communicate with the resident (see observations above).

Based on observations, record review, and interviews, the facility failed to ensure one (#1) of three residents reviewed for falls (#1) out of four sample residents received adequate supervision and assistance to prevent falls with injury. Resident #1 was admitted to the facility on [DATE] for rehabilitation therapy after undergoing surgical repair for a fractured right femur. The facility was aware upon the resident's admission for skilled nursing services that she had several falls in her prior living setting which resulted in the need for surgical repair after the resident fell and fractured her right femur. The facility also was aware that the resident needed to maintain non-weight-bearing status of her fractured leg. The resident was in the facility for two days when she fell on [DATE] at the bedside. Following this first fall, the resident fell an additional four times. The facility failed to prevent the resident from falling on 7/23/24, 7/25/24, 7/30/24, and 8/9/24. According to the director of nursing (DON), the interdisciplinary team (IDT) met after each fall. However, the IDT failed to assess the effectiveness of planned interventions and implement consistent and effective interventions to prevent the resident from repeated falls. The facility failed to consider interventions that had worked well and build upon the most effective interventions to provide consistent care and services to ensure the resident was safe and free from injuries related to accidental falls. The nurse's notes documented that the resident repeatedly tried to get up from her wheelchair and get out of bed. The resident's representative said she asked staff to involve the resident in meaningful activities to distract her from her continual attempts to get out of bed and to keep the resident out of her room. Facility staff provided these services on occasion, but the interventions were not consistently implemented. All the resident's falls occurred in her room from bed when the resident was not under the direct supervision of staff. Facility assessments and nurse's notes revealed that Resident #1 was impulsive, lacked safety awareness, and had a significant impairment in cognitive functioning. Yet, the resident's care plan included encouragement to use the call light, which staff reported the resident was unable to grasp the concept of using, and to wait for staff assistance. Finally, the facility failed to find out why the resident was trying to get out of bed and out of her wheelchair and to offer her sufficient interventions when she expressed a desire to get out of bed and walk. Rather, the record revealed staff tried to redirect the resident back into bed or back into her wheelchair, causing the resident increased agitation and anger. On 7/30/24, the resident experienced her fourth fall in the facility. Following the fall, the resident sustained a dislocated hip at the site of her recent right hip surgical repair. The resident returned to the operating room for a second surgery on the same hip (right) that she fractured a few weeks before. The resident returned to the facility on [DATE] after having her dislocated hip surgically repaired following the 7/30/24 fall in the facility. She was fitted with an immobilizer on her right leg to prevent excessive movement of the leg as it healed. However, the IDT failed to reassess the resident for post-surgical status to determine whether additional interventions needed to be implemented to keep the resident safe as she recovered from her surgery. The resident was in the facility for approximately 48 hours when she fell for the fifth time on 8/9/24 at approximately 11:15 p.m. The resident expressed pain and staff put her in bed as she was in isolation after testing positive for COVID-19. Sometime between (8/9/24) 11:30 p.m. and (8/10/24) 9:00 a.m., the nursing staff heard the resident calling out and when they checked on her, they found that she had removed the immobilizer and her right leg was in an abnormal placement. Staff failed to respond to the resident's change in condition in an appropriate and timely manner. Instead of calling the emergency medical services (EMS), the nursing staff called a mobile x-ray provider to come to the facility to perform an x-ray. At 9:07 a.m., when the technician refused to touch or move the resident, the nurse called the physician for advice on what to do. The staff's response to the resident's change of condition delayed the resident receiving timely assistance for her injury and left the resident in an awkward position, lying on the side of the bed in pain as she waited for a medical professional to respond. Resident #1 was transferred to the hospital again at approximately 9:40 a.m. for surgical repair of her right hip and did not return to the facility. The facility's failure to develop an effective response to the resident's known fall risk factors contributed to the resident re-injuring her repaired right femur (hip) twice. This in turn contributed to pain and two additional surgeries to repair the damage to the resident's right hip. Findings include: I. Facility policy and procedure The Falls and Fall Risk, Managing policy and procedure, revised March 2018, was provided by the nursing home administrator (NHA) on 10/9/24 at 10:38 a.m. It read in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. According to the MDS (minimum data set) assessment, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise when a resident is found on the floor, a fall is considered to have occurred. 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc. 4. In conjunction with the consultant pharmacist and nursing staff, the attending physician will identify and adjust medications that may be associated with an increased risk of falling, or indicate why those medications could not be tapered or stopped, even for a trial period. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 7. In conjunction with the attending physician, staff will identify and implement relevant interventions (hip padding or treatment of osteoporosis, as applicable) to try to minimize the serious consequences of falling. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention causes that may not previously have been identified. II. Resident #1 A. Resident status - known fall risk factors - facility response 1. Known fall risk factors - diagnoses and assessments Resident #1, age over 65, was admitted on [DATE], readmitted on [DATE], and discharged on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, anxiety, depression, insomnia, lack of coordination, muscle weakness and arthritis, presence of right hip fracture, and artificial joint. A fall risk assessment, dated 7/15/24, documented Resident #1 was disoriented to person, place, and time all of the time; had balance problems while standing and walking; decreased muscular coordination; and required the use of a manual wheelchair to get around. At the time of the assessment, the resident had prior falls in the last three months, took medications, and had predisposing diseases increasing her risk for future falls. The resident's fall risk score indicated that she was at risk of falling. A nurse's note, dated 7/16/24, revealed that Resident #1 was admitted to the facility on [DATE] with a diagnosis of right hip hemiarthroplasty (fracture repair) for a skilled therapy stay. The resident was alert and oriented to self only and was confused and forgetful. The resident had poor safety awareness and often attempted to get out of bed on her own. The resident was a fall risk and had three falls while living at a previous memory care unit before admitting to the hospital with a fractured hip. The resident required non-weight bearing on her right leg and used a mechanical lift assisted by two staff when transferring from surface to surface. Despite the need for assistance with transfers, the resident made attempts to get up on her own and needed reminders and encouragement to call staff for assistance. The 7/21/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. The resident used a manual wheelchair for mobility and was unable to walk or put weight on her right leg. -The resident was dependent on staff to transfer surfaces, toilet, bathe, perform personal hygiene, and put on and take off clothing. The resident was occasionally incontinent of bladder and frequently incontinent of bowel. -The resident had a fall in the month before admission with a fracture and had one fall in the facility at the time of the assessment. The resident was taking opioid, antipsychotic, antianxiety, and antidepressant medications. 2. Facility's response A review of the resident's care plan revealed a baseline care plan dated 7/16/24 that documented Resident #1 was a fall risk and was admitted to the facility to improve physical function. Interventions included physical and occupational therapy services. The resident's comprehensive care plan, initiated on 7/17/24, included a care focus for falls, incontinent care, and activity of daily living (ADL) deficits. The care plan revealed: -Resident #1 was at risk for ADL deficits related to a fractured right hip, dementia, need for two staff assistance with transfers, incontinence, and right-sided pain; risk for dislocation of the right repaired hip; and need for continuous cueing to ensure completion of self-care tasks. -Resident #1 was at risk for falling related to a history of falling and sustaining serious injury (fracture to the right hip) before admission to the facility. The resident required assistance with ADLs including mobility, repositioning, toileting, and transferring. The resident required monitoring and prompting due to cognitive impairment, poor safety awareness, and impulsivity. -Resident #1 was independent with mobility when in her manual wheelchair but would try to stand without waiting for staff assistance. The interventions to address the resident's care needs included: assisting the resident with physical needs for repositioning, getting water to drink, constipation, pain, and other care needs, checking for incontinence, performing peri care as indicated three times a day, and providing one to one supervision and encouraging independent and group activities when the resident experienced episodes of anxiety starting 7/17/24. B. Falls after admission Record review revealed the resident was in the facility for two days when she fell for the first time at the bedside. Following the first fall, the resident fell an additional four times, on 7/23/24, 7/25/24, 7/30/24, and 8/9/24. The nurse's notes revealed the resident repeatedly tried to self-transfer from her wheelchair and bed, was confused, became angry when redirected, and was not able to learn or understand how to use the call light. 1. 7/19/24 to 7/23/24 - first fall A nurse's note dated 7/19/24 revealed the resident had a fall witnessed by the nurse as they approached the resident's room. The resident slid from her bed straight down to sit on her bottom (buttocks) on her floor mat. The resident did not hit her head and was at baseline mentation (cognition) when assessed. The resident had AROM (active range of motion) in all extremities and denied having pain. The resident was wearing a nightgown and no shoes at the time of the fall. The bed was in a low position and the fall mat remained in place. A nurse's note, dated 7/20/24, revealed that the resident was at baseline for fall charting related to the witnessed non-injury fall on 7/19/24. The resident was at baseline cognitively but had been exhibiting calling-out behaviors more frequently. Pain medications were administered for pain per the physician's orders. The IDT review note dated 7/22/24 revealed the IDT determined the resident's care plan was being followed at the time of the resident's fall on 7/19/24. The IDT recommended non-skid socks be implemented. 2. 7/23/24 - 7/24/24 - second fall - repeated attempts to get out of bed and wheelchair - failure of the facility to develop effective interventions to address this behavior A nurse's note, dated 7/23/24, documented that the certified nurse aide (CNA) on duty responded to Resident #1's call light at 1:39 a.m., and found the resident trying to get out of bed. The resident was transferred to her wheelchair and provided coffee per the resident's request. Another nurse's note, dated 7/23/24, revealed that while walking by Resident #1's room at approximately 5:45 a.m., the floor nurse heard Resident #1 call out for help when she could not get up off the floor. The resident was found kneeling on the fall mat with her right arm leaning against the bed. The bed was observed to be in the lowest position, the fall mat was in place and the call light was clipped next to the resident's pillow. When asked what happened the resident said she fell and could not get up. The resident complained of pain in the right shoulder and was assessed to have weakness in the right leg (the leg with the hip fracture). The nurse and CNA assisted the resident to bed and applied an ice pack to the resident's right shoulder. The nurse educated the resident to use her call light if she needed assistance. The nurse left a voice message for the resident's physician and notified the director of nursing (DON). A clinical summary note, dated 7/23/24, revealed Resident #1 woke up at 1:00 a.m. (on 7/23/24) and was up in her wheelchair in the hall with nursing staff until 5:00 a.m. The resident was assisted back to bed at 5:00 a.m. and was found on the floor at the bedside at approximately 5:45 a.m. The resident would not go back to sleep after the fall and was assisted back into her wheelchair. Resident #1 complained of soreness in her right shoulder throughout the day after falling but was still able to move her arms and legs. The resident refused offers for pain medication. The summary continued that Resident #1 was restless throughout the day shift and continually attempted to get up out of her wheelchair; removed her oxygen; continually asked staff what she should be doing and at times became worked up and angry towards staff. Resident #1 needed constant redirection and reorientation and was only redirectable for short periods. The note also revealed that the resident was often confused and needed reorientation to the situation, place, and time. The call light was within reach but the resident was unable to learn the use of the call light to ask for assistance, requiring the initiation of frequent checks on the resident throughout the shift. A nurse's note, dated 7/24/24, revealed Resident #1 was up in her wheelchair throughout the day shift. Resident #1 slept some in her chair and made constant attempts to stand on her own from the wheelchair and needed constant reminders and encouragement to stay seated. The resident participated in some (recreational) activities and worked with the therapy providers. Despite the resident's call light being within reach, the note read Resident #1 was unable to learn or understand how to use the call light. It further read the resident has poor safety awareness and is compulsive, staff frequently provide reorientation and redirection. Frequent checks on the resident were provided throughout the shift. Another nurse's note, dated 7/24/24, documented Resident #1 was in bed asleep at 11:20 p.m., with her bed in the lowest position, fall mat in place, and call light within reach. The resident had been instructed to push the call button for assistance. See above; record review revealed repeated documentation of the resident's restlessness, confusion, and frequent attempts to stand on her own from her wheelchair and to get out of bed, prompting the initiation of frequent checks on 7/23/24 and 7/24/24; however, the record failed to reveal the facility identified the reasons why the resident continued to try to self-transfer and how this behavior could be effectively addressed. A review of the resident's care plan failed to include interventions to effectively address the behavior. While the nurse's notes revealed the resident was redirected and reoriented, this was only effective for short periods and, at times, increased the resident's agitation and anger. The resident's representative (see interview below) said she had asked staff to involve the resident in meaningful activities to distract her from her continued attempts to get out of bed and to keep the resident out of her room. Facility staff provided these services on occasion, but the interventions were not provided consistently despite the care plan documenting an intervention for staff to provide one-to-one support and/or encourage group and or individual activities when the resident was presenting with symptoms of anxiety. The facility failed to ensure these interventions were consistently implemented. All the resident's falls occurred in her room from bed when the resident was not under the direct supervision of staff. While the 7/23 and 7/24/24 nurse's notes documented the initiation of frequent checks throughout the shift, this was not added to the care plan. A review of the care plan revealed no revisions to the plan until after the resident's third fall on 7/25/24 (see below). Finally, the review of the nurse's notes for 7/23/24 and 7/24/24 indicated staff continued to remind and encourage the resident to stay seated, to instruct the resident to use her call light for assistance, and to remind the resident to call for assistance, even though the resident was documented as confused and did not understand and was unable to learn the use of the call light. 3. 7/25/24 - 7/30/24 - third fall - repeated attempts to get out of bed and wheelchair - failure of the facility to develop effective interventions to address this behavior. A nurse's note, dated 7/26/24, documented that on 7/25/24 at 9:45 p.m., Resident #1 was observed transferring herself from a low bed and fell on her hands and knees while doing so. It was not known why the resident was trying to get up. A nurse's note, dated 7/27/24, documented that Resident #1 continued to display poor safety awareness related to numerous attempts to get herself out of bed despite her risk for falls, need for assistance, and physician's order to not put weight on her right leg and hip. The note read Resident #1 had been calling out for help and expressing a desire to get up and walk but nobody would help her. Another nurse's note dated 7/27/24 documented that Resident #1 continued to have poor safety awareness and was not redirectable. It read that although fall charting was concluded, increased safety checks, monitoring, and observation of Resident #1 continued as the resident required an increased level of care and attention. Record review revealed the resident's care plan was updated after the 7/25/24 fall. Interventions included frequent rounding to offer toileting assistance every 2 hours and non-skid socks. The following interventions did not include an initiation date: safety measures (keep the resident's room clear and well-lit, select clothing that was easily removed for toileting) - monitor for side effects of medication - move Resident #1's room to the front of the hallway - signs in the room to remind the resident to call for assistance - prompt and anticipate resident needs including for toileting - low bed positioning with a fall mat beside the bed. However, the record failed to reveal the facility identified the reasons why the resident continued to try to self-transfer and how this behavior could be effectively addressed; the facility failed to develop and staff failed to offer the resident sufficient interventions when she expressed a desire to get out of bed and get out of her wheelchair. See above; the resident's fall care plan failed to include specific interventions, such as identifying meaningful activities and identifying the times when the resident was most at risk of self-transfer to minimize the resident's behavior. While the care plan read to round every two hours, there was no indication in the nurse's notes that this would be sufficient given the documentation in the nurse's notes of the resident's frequent attempts to get herself out of bed and out of the wheelchair. Staff recognized in the 7/27/24 nurse's note that the resident required an increased level of care and attention with increased safety checks, monitoring, and observation, but this, too, was not defined or noted on the resident's care plan. The resident's representative (see interview below) said she had asked staff to involve the resident in meaningful activities to distract her from her continual attempts to get out of bed and to keep the resident out of her room. Facility staff provided these services on occasion, but the representative's requests, including engagement in meaningful activities, were not consistently implemented. All the resident's falls occurred in her room from bed when the resident was not under the direct supervision of staff. Further, the record revealed no communication with the resident's representative/family about the resident's need for an increased level of care and attention and how her need could be met. The DON said in an interview on 10/7/24 at 2:22 p.m., that the resident would have benefited from one-to-one supervision. In a later interview on 10/11/24 at 12:00 p.m., as requested by facility leadership (NHA, DON, and corporate consultant), they said that one-to-one supervision would not have been helpful because the resident's behavior was unpredictable and she was noncompliant with redirection. However, there was no evidence in the record of attempts to provide one-to-one supervision and if so, of an interdisciplinary discussion on how to achieve it. 4. 7/30/24 - fourth fall with significant injury A nurse's note dated 7/30/24 revealed that Resident #1 had an unwitnessed fall at approximately 6:50 a.m. The resident was found on the floor at the bedside. An assessment was performed with the resident verbalizing pain in her right hip. The nursing supervisor was notified and the resident was transferred back to bed. A physical assessment was performed by the nurse supervisor and an x-ray was ordered. The x-ray indicated that the resident's right hip was dislocated. The record revealed the resident was hospitalized and returned to the operating room for a second surgery on the right hip that she had fractured earlier. 5. 8/7/24 - 8/10/24 - resident readmission - fifth fall 8/10/24 - failures in response a. Status on readmission - facility failure A nurse's note, dated 8/7/24, revealed Resident #1 was readmitted to the facility for a skilled rehabilitation stay with a diagnosis of open reduction to the right hip with tissue repair. Upon her return, record review and interview revealed the resident was tested for COVID-19; after testing positive, the resident was placed in isolation in her room. The record further revealed Resident #1 returned to the facility with an immobilizer on her right leg to prevent excessive movement of the leg as it healed. An interview with the DON on 10/7/24 at 2:22 p.m. revealed the resident would not leave the immobilizer alone and was observed picking at her wound dressing and the immobilizer. A nurse's note dated 8/8/24 revealed the resident continued to work with rehabilitation therapies, was restless at times, and continued attempting to self-transfer from bed (without calling for staff assistance). A nurse's note, dated 8/9/24, documented that Resident #1 continued to be agitated. Calling out to staff Help me, Come here. Her daughter visited for one hour the previous evening and the resident had decreased agitation for a few hours after the visit. Despite the resident's known behavior to self-transfer and her recent surgery, record review revealed the IDT failed to reassess the resident when she returned to the facility on [DATE] to determine whether additional interventions, such as one-to-one supervision, needed to be implemented to keep the resident safe from further injury while isolated in her room post-surgery. b. Fifth fall - facility failure A nurse's note revealed the resident was back in the facility for approximately 48 hours when she fell for the fifth time on 8/9/24 at approximately 11:15 p.m. Record review revealed the facility failed to appropriately and timely address the resident's fifth fall, delaying treatment by medical professionals for her injuries and pain. A nurse's note, dated 8/10/24, documented on 8/09/24 at 11:15 p.m., Resident #1 was observed during rounds by a CNA sitting on a fall mat in front of her bed with her feet in front of her. The circumstances of the fall were unknown. The resident was disoriented at baseline. Range of motion (ROM) in her right leg was restricted related to postoperative pain and the resident's ability to cooperate with the assessment. Able to transfer to bed with two staff assistants. Vital signs were within normal limits and the resident had no increase in baseline pain. The physician ordered an immediate x-ray. The note further read: -Resident #1 was calling out (in the early hours of the morning). When staff checked in on Resident #1 she was observed to have her feet off the bed. The nurse and CNA entered the room and attempted to assist the resident back into bed but immediately noticed that the resident's right hip and leg did not look appropriate to her body frame. The resident had removed her immobilizer from her right leg. -Upon assessment, the resident's right leg rotated inward as well as the right knee and foot with the right hip appearing to be sticking upwards and outwards. The resident's left leg was slightly bent at the knee but looked appropriate to her frame. The staff did not move the resident. A second nurse assessed the resident and agreed the placement of the resident's right leg was not correct. Staff called for a mobile x-ray provider to come to the facility to perform an x-ray. -The resident was left in the same position that she was found in while waiting for the mobile x-ray technician to arrive. Resident #1 told staff she was in pain. The x-ray technician arrived, looked at the resident and told the staff that he was not going to touch the resident out of concern for causing the resident further injury. -After the technician left, the resident was left in the same position with her right leg hanging off the side of the bed. Nursing staff placed a clean brief under the resident and the nurse called the physician's office (at approximately 9:07 a.m.) for guidance and was directed to call an ambulance to transport the resident to the emergency room for assessment and treatment. The ambulance arrived to transport the resident to the hospital at approximately 9:40 a.m. E. Resident representative interview On 10/8/24 at 1:26 p.m., the resident's representative was interviewed. The representative said she was highly concerned about the care Resident #1 received while in the facility. She felt a need after the resident had fallen three times (7/23/24, 7/25/24, and 7/30/24) to make frequent inquiries about the resident's care. The representative said that Resident #1 did not get safe care. She said she had asked staff to keep Resident #1 out of her room and involved in meaningful activities to try to distract her from her continual attempts to get out of bed and out of her manual wheelchair. The representative said Resident #1 seemed to be distracted and confused by group activities and maybe would have done better with one-to-one or smaller group activities where staff would be able to be more engaged with her. The representative said when the resident fell on [DATE], her right hip became dislocated as a result and the resident was sent to the hospital. The medical staff tried three times to get the resident's hip back into place but were unable to do so and the resident had to undergo a surgical procedure to restore hip placement. The resident was then readmitted to the facility on [DATE], and two days later, she fell again, damaging her hip and requiring another surgical procedure. F. Staff interviews The DON was interviewed on 10/7/24 at 2:22 p.m. The DON said Resident #1 was admitted in a very disoriented state. The family put signs up in her room to prompt the resident to call for staff assistance and not to get up to walk on her own. However, the resident's cognition was severely impaired and she was not able to understand the signs. The facility tried getting the resident to attend group activities and encouraged the resident to sit in public areas where staff could watch her but she resisted. The DON said the physician was making adjustments to the resident's medication to help the resident better manage her anxiety and insomnia and the resident was moved to a room closer to the nurse's station. The DON said when they admitted a resident with a high risk for falls or someone who fell frequently, they tried to not place too many limiting interventions on a resident all at once because they did not want to be too restrictive with the resident. The DON said, in hindsight, the resident really needed a constant one-to-one sitter but that was not something the facility was able to provide. The nursing home administrator (NHA) and the DON were interviewed on 10/8/24 at 12:16 p.m. The NHA said they were able to provide Resident #1 with one-to-one staffing on the overnight shift but they were not able to maintain that level of staff consistently. The DON said most of the time, Resident #1 did not listen to staff and was not redirectable. The DON said they tried to implement interventions slowly, starting with keeping the resident's bed in a low position and providing a bedside fall mat. After the resident's first fall on 7/17/24, they implemented and provided the resident with non-skid socks. Each fall was assessed by the IDT and they found that the care plan was being followed each time. The DON was not sure what other interventions could have been provided. Staff were trying to anticipate the resident's needs and make [TRUNCATED]

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 diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure residents were offered an opportunity for hand hygiene prior to dining. Finding include: I. Housekeeping failures A. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical recommendations for routine cleaning and disinfection procedures in healthcare institutions: a narrative review. The Journal of Hospital Infection. 2021 Jul;113:104-114 was retrieved on 6/22/23 revealed in pertinent part: High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease) Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stay, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment. The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 6/22/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Common high-touch surfaces include: -bedrails -IV (intravenous) poles -sink handles -bedside tables -counters -edges of privacy curtains -patient monitoring equipment (keyboards, control panels) -call bells -door knobs Proceed From Cleaner To Dirtier Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: -During terminal cleaning, clean low-touch surfaces before high-touch surfaces. -Clean patient areas (patient zones) before patient toilets. -Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone. -Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions. B. Facility policy and procedure The Housekeeping Services policy and procedure, last revised August 2013, was provided by the director of nursing (DON) on 6/20/23 at 2:35 p.m. It read in pertinent part, The facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Resident Room Cleaning: 1. Gather supplies as needed. 2. Prepare disinfectant according to manufacturer's recommendations. 3. Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solution. 4. Change mop solution water at least every three (3) rooms, or as necessary. 5. Change cleaning cloths when they become soiled. Wash cleaning cloths daily and allow cloths to dry before reuse. 6. Clean horizontal surfaces (bedside tables, overbed tables, and chairs) daily with a cloth moistened with disinfectant solution. Do not use feather dusters. 7. Clean personal use items (lights, phones, call bells, bedrails) with disinfectant solution at least twice weekly. 8. When cleaning rooms of residents on isolation precautions, use personal protective equipment as indicated. 9. When possible, isolation rooms should be cleaned last and water discarded after cleaning the room. 10. Utilize disinfectant solution based on type of precaution. 11. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. 12. Clean spills of blood or body fluids as outlined in the established procedure. C. Manufacturer recommendations The disinfectant in the facility was identified as: CloroxPro Healthcare Fuzion Cleaner Disinfectant Spray The product label was reviewed which read in pertinent part, Clorox Healthcare Fuzion Cleaner Disinfectant is a one-step, fast acting, ready-to-use cleaning spray that combines the trusted efficacy of bleach with excellent surface compatibility and low odor. This next-generation bleach product is EPA (Environmental Protection Agency)-registered to kill 53 microorganisms with a 2 minute kill time for C. difficile spores, the fastest kill time available, based on comparison of EPA master labels as of March 2018, and a 1-minute kill time for a broad range of bacteria, viruses and fungi. D. Observations On 6/20/23 housekeeper (HSKP) #1 was continuously observed cleaning rooms #509, #510, #511 and #514 from 9:09 a.m. to 10:24 a.m. HSKP #1 wiped the surfaces in each room with a cloth that she sprayed the disinfectant onto. HSKP #1 wiped surfaces in each room (bed frame, door knobs, tray table, closet and chair) for five seconds per surface. The surface was no longer wet within five seconds from when the disinfectant was applied; the surface disinfectant time was not followed. The disinfectant was applied to a cloth and not directly sprayed on the surface. The call light in the room was not disinfected (see above per CDC guidelines). On 6/20/23 HSKP #2 was continuously observed cleaning rooms #403, #411 and #413 from 9:47 a.m. to 10:53 a.m. HSKP #2 wiped surfaces in each room (bed frame, door knobs, tray table, closet and chair) for eight seconds per surface. The surface was no longer wet within 30 seconds from when the disinfectant was applied; the surface disinfectant time was not followed. The disinfectant was applied to a cloth and not directly sprayed on the surface. The call light in the room was not disinfected (see above per CDC guidelines). E. Interviews HSKP #2 was interviewed on 6/20/23 at 10:45 a.m. HSKP #2 said she did not disinfect the call light in all rooms that she cleaned and she did not adhere to the surface disinfectant time of the Clorox disinfectant. HSKP #1 was interviewed on 6/20/23 at 10:54 a.m. HSKP #1 initally said the Clorox disinfectant did not have a surface disinfectant time (the time the disinfectant needs to remain wet on a surface in order to kill pathogens). HSKP #1 returned with the NHA at 11:09 a.m. and said the surface disinfectant time was two minutes for the product. HSKP #1 provided a demonstration of disinfecting the door knob to the supply room in the presence of the NHA. HSKP #1 disinfected the surface by spraying the cloth and wiped the surface for five seconds, the door knob was dry immediately after it was wiped. HSKP #1 failed to adhere to the proper surface disinfectant time (see manufactures recommendations above). The NHA provided training to HSPK #1 on the proper surface disinfectant time. The director of nursing (DON) was interviewed on 6/20/23 at 11:35 a.m. The DON said surface disinfectant times should be adhered to be effective in killing germs, viruses and bacteria. The DON said if the surface disinfectant time was not adhered to then a surface would not be clean or disinfected, which could lead to potential infection. High frequency touch areas should be disinfected. The director of housekeeping (DOH) was interviewed on 6/20/23 at 12:13 p.m. The DOH said rooms should be cleaned top down, dirtiest to cleanest. All high frequency touch areas in the room should be disinfected daily, however, she did not consider the bathroom call light cord to be a high frequency touch area. The DOH said surface disinfectant times should be adhered to ensure surfaces were properly disinfected and based on the deficient practice identified she needed to provide training to all housekeeping staff that covered surface disinfectant times, room cleaning procedures and high frequency touch areas. II. Resident hand hygiene failures A. Observations On 6/14/23 residents in the dining hall were observed continuously from 11:58 a.m. to 12:53 a.m. Certified nurse aide (CNA) staff assisted residents into the dining hall for lunch. Approximately 12 residents that ate in the dining hall were not offered hand hygiene prior to eating. One resident was eating a grilled cheese sandwich, considered a ready-to-eat food. On 6/15/23 meal trays were observed continuously from 4:45 p.m. to 5:15 p.m. The nursing home administrator (NHA) and director of nursing (DON) passed out eight meal trays to room [ROOM NUMBER], #515, #517, #518, #505, #507, #508 and #504. The NHA and DON did not offer residents an opportunity to engage in hand hygiene prior to eating. The meal trays did not include hand sanitizer and or wipes for residents to use prior to eating. B. Staff interview The DON was interviewed on 6/20/23 at 11:35 a.m. The DON said staff and residents should engage in hand hygiene to prevent the spread of infection and if someone had visibly soiled hands they should wash their hands with soap and water.

Based on observation, record review, and interviews, the facility failed to develop and implement person-centered care plans consistent with professional standards of practice and the residents goals and preferences for four (#23, #26, #34 and #35) of six residents out of 13 sample residents who were prescribed anticoagulant medication. Specifically, the facility failed to ensure Resident's #23, #26, #34 and #35 were provided a comprehensive care plan focus for anticoagulant therapy. Where the care focus included measurable objectives, interventions and timeframes in line with the resident's medical condition, goals and preferences for anticoagulant therapy; in order for staff to meet the resident's care needs. Findings include: I. Facility policy The Care Plans, Comprehensive Person-Centered policy, revised December 2016, was provided by the nursing home administrator (NHA) on 6/21/23 at 5:24 p.pm read in pertinent part: The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, patient-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive patient centered care plan will: Describe the services that are to be furnished to maintain the resident's highest practical physical, mental and psychosocial wellbeing. Incorporate identified problem areas, incorporate risk factors associated with identified problems. Identify the professional services that are responsible for each element of care. Reflect on correctly recognized standards of practice for problem areas and conditions. II. Resident #23 A. Resident status Resident #23, age 90, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included aphasia following cerebral infarction (stroke), chronic kidney disease stage 3, hemiparesis (one-sided paralysis) following cerebral infarction (stroke), atrial fibrillation (irregular and fast heart rate), coronary heart disease (obstruction of blood vessels in the heart) and long term (current) use of anticoagulant(s) (blood thinning medications). The minimum data set (MDS) dated [DATE] revealed the resident had severely impaired cognition as evidenced by a brief interview for mental status (BIMS) score of six out of 15. The MDS documented the resident was at risk of skin injury and recommended formal skin assessment/clinical assessment due to the risk of skin injury. The resident received anticoagulant medications. B. Resident observations 6/15/23 at 12:00 p.m. The resident had a quarter sized bruise on the left wrist between the back of her hand and wrist. C. Resident interview The resident was interviewed on 6/20/23 at 10:15 a.m. The resident said the bruise to her left wrist was the result of her watch. The resident said she did not have any additional bruising on her body that she was aware of. The resident said she had two blood clots and was prescribed a blood thinner for the health of her heart and brain. The resident said the staff advised her to not hit her head and to ask for help with transferring to and from the manual wheelchair to avoid a fall. The resident said she had been taking blood thinners for years but did not remember how long. The resident's spouse said the resident had started taking blood thinners after a stroke but did not recall the year the resident had a stroke. D. Record review The June 2023 CPO documented an order for Eliquis (anticoagulant medication), give the resident 5 milligrams (mg) by mouth twice a day, prescribed 2/20/23. -The resident's comprehensive care plan dated 1/31/23 did not have a care focus with individualized interventions to address the use of anticoagulant therapy. III. Resident 26 A.Resident status Resident #23, age 92, was admitted on [DATE]. According to the June2023 CPO, diagnoses included hypertensive chronic renal disease, stage 3, type 2 diabetes mellitus and dysphagia (difficulty swallowing). The MDS dated [DATE] revealed the resident had severely impaired cognition as evidenced by a BIMS score of zero out of 15. The MDS assessed the resident to be at risk of skin injury and recommended formal skin assessment/clinical assessment due to risk of injury. The MDS assessment did not identify that the resident received anticoagulant medications. B. Resident observations 6/21/23 at 3:55 p.m. The resident had a small dime sized purple discoloration to her right forearm. The rest of the resident's body was covered and not visible. C. Resident interview The resident was not interviewable. D. Record review The June 2023 CPO documented an order for Clopidogrel (Plavix) (anticoagulant medication) give the resident 75 mg by mouth daily, prescribed 2/21/23. -The resident's comprehensive care plan did not have a care focus with individualized interventions to address the use of anticoagulant therapy. IV. Resident 34 A. Resident status Resident #34, age 84, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included interstitial pulmonary disease (disorder that causes lung scarring), arteriosclerotic heart disease (hardening of the arteries), polyneuropathy (damage to nerves outsid e the brain and spinal cord), venous thrombosis/embolism (blood clots) and osteoporosis (decrease in bone mass). The MDS dated [DATE] revealed the resident had moderate impaired cognition as evidenced by a BIMS score of nine out of 15. The MDS documented the resident was at risk of skin injury and recommended formal skin assessment/clinical assessment due to risk of injury. The MDS did not identify the resident received anticoagulant medication. C. Resident interview The resident was interviewed on 6/21/23 at 5:15 p.m. The resident said she took a lot of medicine and did not know why she was prescribed a blood thinner nor could the resident recall the need for a blood thinner medication. The resident said she had a few bruises on her legs from bumping into things and thought maybe she bumped her legs on the bed frame in her room. D. Record review The June 2023 CPO documented an order for Clopidogrel (Plavix) (anticoagulant medication) give the resident 75 mg by mouth daily, prescribed 11/27/22. -The resident's comprehensive care plan did not have a care focus with individualized interventions to address the use of anticoagulant therapy. V. Resident #35 Resident #35 , age 93, was admitted on [DATE]. According to the June 2023 CPO, diagnoses included, hypertensive (high blood pressure), long term use of anticoagulants, atrial fibrillation (irregular and fast heart rate), transient ischemic accident (stroke that lasts for a few minutes), cerebral vascular accident (loss of blood flow to the brain) and presence of cardiac pacemaker (device implanted in the chest to help control the heart beat). The MDS dated ,d+[DATE] revealed the resident had severely impaired cognition as evidenced by a BIMS score of five out of 15. The MDS assessment documented the resident was at risk of skin injury and recommended formal skin assessment/clinical assessment due to risk of injury without current skin problems. The resident had received anticoagulant medication. B. Resident observations 6/21/23 at 3:20 p.m. The resident had several areas of brown discoloration on her right forearm and a small skin tear on the right hand. C. Resident interview The resident was not interviewable. D. Record review The June 2023 CPO documented an order for Eliquis 2.5 mg, give to the resident twice per day by mouth, daily, prescribed 4/9/22. -The resident's comprehensive care plan did not have a care focus with individualized interventions to address the use of anticoagulant therapy. VI. Staff interviews The director of nursing (DON) was interviewed on 6/21/23 at 9:40 a.am. The DON said the facility staff complete weekly skin assessments for residents taking medication that could result in bruising to the skin. The staff look for signs and symptoms of increased bleeding or bleeding in stool and/or urine and for bleeding overall. The DON said resident comprehensive care plans were inclusive to the resident's diagnoses, past medical history, activities of daily living, preferences, prescribed medication and physical assessment on admission. The nurse practitioner (NP) was interviewed on 6/21/23 at 10:10 a.m. The NP said the plan of care should identify the resident at risk for skin injury related to prescribed medication side effects and provide interventions to those situations that could potentially impact skin integrity. Registered nurse (RN) #5 was interviewed on 6/21/23 at 3:11 p.m. RN #5 said the plan of care was to be completed within 14 days of admissions and was to be updated with any and all changes in condition, including new treatments, new medication, new diagnosis, new behaviors and medication additions or medication changes. RN #5 said the care plan should include intervention for monitoring the resident for medication side effects as appropriate; this would include monitoring for use of anticoagulant medication. When a resident was on anticoagulant therapy the care plan should include interventions to monitor for bleeding and bruising, interactions with other medications and the need for routine and as needed lab work.

Based on record review and interviews, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a need to alter treatment significantly for one resident (#41) of two residents reviewed out of 35 sample residents. Specifically, the facility failed to make a timely notify Resident #41, the resident's representative and the prescribing physician (wound specialist) that the interdisciplinary team (IDT) made a decision to not start the resident on antibiotic treatment prescribed by the wound care physician (WP). Findings include: I. Facility policy The Change of Condition policy was provided by the nursing home administrator (NHA) on 6/21/23 at 3:21 p.m., it read in pertinent part: Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical /mental condition and /or status. Policy Interpretation and Implementation: The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly. A 'significant change' of condition is a major decline or improvement in the resident's status that: Requires interdisciplinary review and/or revision to the care plan; and ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. II. Resident #41 A. Resident status Resident #41, age [AGE] years old, was admitted on [DATE] and discharged on [DATE]. According to January 2023 computerized physician orders (CPO) diagnoses included chronic venous hypertension (increased pressure in the veins) with ulcer (an open wound due to poor blood flow) to the both lower extremity; cellulitis (an infection of the deeper layers of skin and the underlying tissue) in the right lower limb; and type 2 diabetes. The 1/26/23 admission minimum data set (MDS) assessment revealed Resident #41 had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was assessed to have clear comprehension. The resident had one venous ulcer present on admission. B. Resident interview Resident #41 was interviewed on 6/21/23 at 2:10 p.m. Resident #41 said that when he was in the facility back in December 2022 to January 2023 the facility never provided him any antibiotics. Resident #41 said he was never told that facility staff made a decision not to provide him prescribed antibiotic medication. He was still unsure why this decision had been made to not provide him the prescribed antibiotics. The resident said there had been some confusion from the nursing staff that became apparent during a care conference meeting with staff and his family. The nurse told him he was taking antibiotics and even described the antibiotic pills' appearance. Resident #41 said he told the nurse that was not accurate and he was sure he had not ever received a pill like the nurse described. He knew this to be true because he always looked over all his pills when the nurse brought him his medications and a pill matching that description had never been given to him. The nurse remained adamant throughout the meeting that he was mistaken. Later he and his family got confirmation that he had never been on any antibiotic medication during his stay. Resident #41 said that nursing staff had not informed him that his wound care treatment plan of care changed until he and his family asked questions. It was not until days after that care conference meeting that he learned more about why he was not getting his prescribed antibiotic medication. C. Record review The baseline care plan dated 12/20/23 documented that the resident had a wound on the legs, toe and ankle. Problem statement: Risk of impaired skin integrity; Goal: resident will have no skin breakdown during stay. -There was no care focus to treat the resident identified wounds. Wound tracker notes documented the following information: -Physician note dated 12/20/22 read in pertinent part: Wound: Location second toe; etiology venous ulcer; dimensions: 0.5 centimeters (cm) by 0.5 cm by 0.1 cm with 80 percent granulation (development of new skin) and 20 percent slough (dead tissue, usually cream or yellow in color); with a small amount of serosanguineous drainage (fluid contains part blood and part liquid serum). Periwound (the area surrounding the wound): erythema (superficial redness) and pain. Wound: Location: right shin; etiology: blister; dimensions; 8 cm by 7 cm by 0.1 cm with granulation 80 percent, slough 20 percent; and a moderate purulent drainage(a sign of infection characterized by a slightly thick white, yellow, or brown fluid); periwound: erythema (superficial redness), pain and edematous. Wound: Location: left shin; etiology: blister; dimensions; 2 cm by 2 cm by 0.1 cm with slough 100 percent; drainage: small amount of serosanguineous drainage; periwound: erythema (superficial redness), pain and edematous. Wound: Location: left malleolus (hammer shaped bone on the outside of the ankle); etiology: venues ulcer; dimensions; 1 cm by 0.8 cm by 0.1 cm with slough100 percent; with a small amount of purulent drainage; periwound: erythema and pain. Wound Notes: Start resident on Keflex (antibiotic medication) 500 milligrams (mg) by mouth three times a day for seven days. Recommend skill nursing to monitor wounds. -Review of the December 2022 CPO electronically signed by the resident's primary care physician on 1/3/23 (14 days after the WP ordered antibiotic treatment) revealed no documentation of the order for Keflex being placed or documented in the resident's medication administration record. Care conference sign in sheet revealed there was a care conference meeting held on 12/27/22 with Resident #41, the resident's son, daughter, the social services director, nursing staff and a representative from the resident's prior living facility. -There were no notes documenting what was discussed. Primary Care visit note dated 12/27/22, revealed the resident was seen by an attending physician provider. The provider note read in part: Resident has a shallow non-pressure related ulceration of the right anterior calf. He has recurrent large fluid filled blisters that break down to open wounds. This wound has been present for over a week, it is large, last week the legs were very red, the wound was draining and had a foul odor, wound RN (registered nurse) was concerned about infection and started him on Keflex, wound care has been exceedingly difficult . Assessment and Plan: Non-pressure chronic ulcer of unspecified part of right lower leg limited to breakdown of skin: this wound is starting to heal and the infection/inflammation of the legs is resolving with good wound care and abx (antibiotic) . the biggest issue is getting (the resident) consistent wound care ., if (the resident) does not have this in place when he goes back to AL (assisted living) then this situation will occur again and he will be at risk for severe skin breakdown and possibly even severe infections with sepsis. -The above noted document, written by the attending physician's assistant, revealed that the primary care medical provider believed the resident was taking the prescribed Keflex antibiotic and documented no awareness that the IDT member's (members of the IDT were unknown) had made a determination that the resident was appropriate for antibiotic treatment. -There was no documentation within the above document to indicate that the facility's nursing staff review the provider's assessment and medical plan of care to ensure accurate notification and coordination of care (see the director of nursing interview below). Review of progress notes revealed: Late entered note: IDT review note entered date 12/29/22 at 10:37 p.m., effective date 12/22/22; written by the NHA (licensed only as a NHA not as a licensed nurse) read: IDT review of ABX (antibiotic) stewardship yielded that patient was not appropriate for recommended course of Keflex based on not meeting McGreer Criteria (provides standardized guidance for infection surveillance activities); absence of four or more present signs of soft skin tissue/wound. Interventions in place: Residents moved to skilled nursing for consistent nursing monitoring of wound and wound care. -There was no documentation of which specific conditions, based on McGreer Criteria, the decision to not provide the resident the prescribed antibiotic was made. Additionally, there was no documentation to indicate which staff participated in the IDT review meeting to make this determination that the prescribed antibiotic was not appropriate for the resident wounds (see director of nursing interview below for more information). There were no nursing or physician notes about the decision. A request was made to the director of nursing (DON) for detailed documentation of the IDT review meeting (see NHA note above); including documentation on the McGreer Criteria assessment and a list of attendees and none was provided (see DON interview below) by the survey exit on 6/22/23. III. Staff interviews The DON was interviewed on 6/21/23 at 4:20 p.m. The DON said the nursing staff never received an order form attending physician provider administer antibiotic medication to Resident #41; so no antibiotics were provided to the resident. The DON was unable to explain when the IDT reviewed the resident for antibiotic stewardship for recommended courses of Keflex, if they did not have an order to prescribe antibiotics. The DON acknowledged the wound tracker from the wound care physician contained wound care treatment orders, but said the facility was unable to take medication orders from the wound care physician; the physician's order had to come from the resident attending physician. The DON said she did not know if the WP's order to start the resident on Keflex was ever discussed with the attending physician. The DON provide the attending physician visit notes (see attending physician provider notes above). During the interview with the DON, the provider's notes were reviewed and the DON was unable to explain why the provider wrote in the 12/29/22 visit/exam note that the resident was taking Keflex antibiotic medication when the resident was not taking the medication. The DON said nursing staff did not review physician notes so she was unaware of what the providers wrote in their notes. The DON said when the facility received the medical note from medical provider's no one from nursing staff reviewed the notes and they were just uploaded to the resident's medical record; The DON acknowledged there was no nursing coordination of care between the physician notes and the provider assessment and plan of care. The DON said she was not sure if the WP was ever made aware that the order for Keflex antibiotic medication had not ever been administered to the resident when the IDT made the determination that the Keflex was not appropriate. The DON said she had not been present during the resident's care conference meeting; instead the assistant director of nursing (ADON), who no longer worked in the facility, was at the meeting so she did not know what was discussed. Additionally, she was not a member of the IDT review meeting to discuss whether or not the prescribed Keflex antibiotic medication was appropriate for the resident. The ADON attended the meeting and would have been the one to notify the resident and the resident providers of the decision.

Based on interviews, observations and record review, the facility failed to ensure one (#17) of one resident reviewed for activities of daily living of 35 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to ensure that Resident #17 received timely incontinent care after the resident had an episode of involuntary leakage of urine and feces. Findings include: I. Facility policy and procedure The Urinary Continence and incontinence- Assessment and Management policy, revised on August 2022, was provided by the nursing home administrator (NHA) on 6/22/23 at 5:21 p.m. It documented, in pertinent part: The management of incontinence will follow relevant clinical guidelines. As indicated, and if the individual remains incontinent despite treating transient causes of incontinence the staff will initiate a toileting plan. A 'check and change' strategy involves checking the resident's continence status at regular intervals and using incontinence devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. II. Resident #17 A. Resident status Resident #17, age 94, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included displaced fracture of left tibia tuberosity (a bony bump on the upper part of the shin where the patellar tendon attaches the quadriceps muscles (or quads) to the leg), muscle weakness, osteoarthritis (most common form of arthritis) and scoliosis (a sideways curvature of the spine). According to the 5/31/23 minimum data set (MDS) assessment, the resident was severely cognitively impaired with a brief interview for a mental status score of seven out of 15. The resident required extensive assistance of two persons with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was incontinent of bowel and bladder and was at risk of pressure ulcers. B. Observations and interview On 6/14/23 observations of Resident #17 included: -At 9:38 a.m. there was a distinct urine and feces odor coming from Resident #17's room. -At 11:45 a.m. a companion aide contracted to sit with the resident (not a facility employee) was observed in the resident's room. The room had a strong smell of feces and urine. The sitter said when she came in at 10:00 a.m. the previous sitter told her that the resident was laying on a sheet that had feces on it. The sitter said the resident had an accident and they changed the resident but left the soiled sheet underneath her. The sitter said the certified nurse aides (CNAs) changed the resident and made the decision to keep the sheet underneath the resident because the resident had an appointment later. The sitter said she was contracted as a companion aide to sit with the resident and was unable to provide any hands-on personal care tasks like incontinent care for the resident, unless they were assisted and supervised by facility staff during the task. On 6/15/23 during a continuous observation, from 1:30 p.m. until 4:59 p.m. no staff entered the resident's room to check on the resident or provide incontinence care. -At 4:59 p.m. registered nurse (RN) #2 entered the residents room to deliver a food tray. The room had a strong odor of feces. RN #2 did not notify the CNAs to provide incontinence care. On 6/20/23 during continuous observations from 9:15 p.m until 2:00 p.m. the following was observed: -At 9:15 a.m. the resident's door was shut but there was a strong odor of feces coming from the Resident #17's room, which could be smelled in the hallway even with the resident's door being shut. The door remained shut until 9:37 a.m when the resident's sitter staff exited the room to bring out the resident's food tray. -At 9:55 a.m. the smell of feces and urine coming form resident #17's room was stronger and could be smell from a couple of doors away from Resident #17's room. Housekeeper (HSKP) #1 went into the resident's room to clean. HSKP #1 finished cleaning and removed the trash from the resident's room and the resident's room and hallway outside the resident's room still had a strong smell of urine and feces. -At 10:29 a.m. CNA #4 went into the Resident #17's room and brought the resident water. The CNA did not check the resident or provided incontinent care and the odor of feces and urine coming from the resident room was still present. -At 11:43 a.m. CNA# 4 stopped by Resident #17's room and asked the contracted sitter if everything was okay.The sitter said they were fine. CNA #4 did not enter the room. -At 11:51 a.m. the NHA looked into Resident #17's room but did not say anything. The strong smell of urine and feces continued to be present and still could be smelled both inside the resident's room and into the hallway. -At 11:54 a.m. staff delivered lunch to Resident #17 staff did not ask the sitter anything or provide care to the resident. The sitter helped the resident eat her lunch. -At 1:11 p.m. the sitter came out of the Resident #17's room to ask about an appointment, but said nothing about Resident #17 needing to be cleaned up and changed. -At 1:21 p.m. CNA #4 and CNA #2 went into the resident room and asked the sitter to help them change the resident. Upon beginning to provide care the three found that the Resident #17's body, clothing and sheets were saturated with feces and urine and called RN #4 to assist them change the resident. -At 1:50 p.m. the CNAs, RN and the sitter complete the process of getting Resident #17 cleaned up and into clean clothing and linens. CNA #4 said the resident's sheets and clothes were heavily soiled with both urine and feces and that the feces was up to the middle of the resident's back. C. Record review The incontinent care plan, initiated on 6/21/23, documented the resident required toileting assistance to be met by facility staff. Interventions included: Monitor the resident for incontinent episodes; change pads/briefs every two hours and as needed. The skin breakdown care plan, initiated on 6/21/23, documented the resident was at risk for skin breakdown related to incontinence. Interventions included: Check for incontinence three times a day. Change if wet or soiled. Clean skin with mild soap and water. Apply a moisture barrier cream. The companion/sitter contract, dated 2/23/09, documented the (provider name) employees were able to do the following tasks: Help the resident out of bed; help with morning routine; provide bathing assist; dressing assistance, laundry assistance, and meal assistance; assistance with ambulation; take to activities; help to bed at night; offer bathroom reminders; assist to the bathroom; and visit with the resident. III. Staff interview CNA #4 was interviewed on 6/20/23 at 3:14 p.m. CNA #4 said residents should be offered incontinence care and repositioning every two hours. CNA #4 said the CNAs were responsible for checking the residents for incontinence care even when the resident had outside help. CNA # 4 said if there was a urine or feces odor, the CNAs should check to see if the resident was incontinence and needed to be cleaned and changed. CNA #4 said Resident #17 was incontinent and required total assistance with repositioning and incontinence care. RN #4 was interviewed on 6/21/23 at 8:37 a.m. RN #4 said CNAs were responsible for checking and changing residents for incontinent care. RN #4 said residents who needed full assistance with incontinence care should be checked every two hours and should be provided additional checks and changes if the resident had an odor of urine and feces. RN #4 said the contracted sitters were not permitted to provide resident care on their own and needed a facility employee to perform the service; however, the sitter was permitted to help facility staff during care. RN #4 said Resident #17 did not know when she needed to be changed and required full assistance with incontinent care. The director of nursing (DON) was interviewed on 6/21/23 at 4:26 p.m. The DON said residents who needed assistance with incontinence care need to be checked and changed every two to three hours and as needed. The DON said if an odor of urine or feces was detected coming from a resident should be checked and changed if soiled. The DON said the contracted sitters did not assist in providing direct care to the residents. The DON said facility staff should not expect the contracted sitters to check a resident for incontinent episodes. The facility CNAs were responsible to check the residents for incontinent episodes. The DON said Resident #17 should not be laying on a soiled sheet and the sheet should have been changed right away. The DON said facility CNAs should been checking Resident #17 at least every two hours and change the resident as soon as the resident had an odor of urine or feces.

Based on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#41) out of 35 sample residents. Specifically, the facility failed to ensure Resident #41's medical record regarding the clinical justification for why a prescribed treatment for wound care treatment, antibiotic medication was not provided was documented and documented accurately. Cross-reference F580, timely notification to the resident prescribing physician, the attending physician and the resident representative. Findings included: I. Resident #41 A. Resident status Resident #41, age [AGE] years old, was admitted on [DATE] and discharged on [DATE]. According to January 2023 computerized physician orders (CPO) diagnoses included chronic venous hypertension (increased pressure in the veins) with ulcer (an open wound due to poor blood flow) to the both lower extremity; cellulitis (an infection of the deeper layers of skin and the underlying tissue) in the right lower limb; and type 2 diabetes. The 1/26/23 admission minimum data set (MDS) assessment revealed Resident #41 had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident was assessed to have clear comprehension. The resident had one venous ulcer present on admission. B. Resident and resident represented interview The resident representative was interviewed on 6/20/23 at 4:15 p.m. The resident representative said she was present at a care conference meeting on 12/27/22 and the nurse in attendance was insistent Resident #41 was taking antibiotics medication despite the resident telling the attendees differently. After the meeting, the resident and family requested the resident's medical records to be reviewed and discovered the resident was correct at not being provided antibiotic medications. The resident and family discovered by reviewing the resident's medical record that two days after the meeting was over a facility staff wrote a note in the resident's medical records documenting that the resident did not need antibiotics and had not received antibiotics. The note was written on 12/29/22 was backdated to 12/22/22, to five days prior to the care conference meeting she attended where they were told the resident was taking antibiotic medication. The family was concerned that nursing staff did not know what they were doing and concerned about the inaccuracy between what the nursing staff and medical provider thought was occurring regarding the resident's care and what was written in the medical record. Cross-reference to F580 failure to immediately notify the resident, the resident's attending care providers and the prescribing physician when treatment orders were changed. Resident #41 and the resident representative and resident's power of attorney (POA) were interviewed on 6/21/23 at 2:10 p.m. The POA said the resident and family were very concerned after reviewing the resident's medical records requested of the facility for the stay from 12/20/22 to 1/24/23. The concerns arose when the (assistant) director of nursing (DON) told the resident and family during a care conference that the resident had been taking Keflex antibiotic medication when the resident was not provided any of the antibiotic medication prescribed by the wound care provider. The medical record had only one backdated note written nine days after the medication was prescribed that the facility decided the medication was not appropriate. There was no documentation form the prescriber for why the medication had not been provided and the primary care provider wrote a note in the resident's record that the resident had been taking the prescribed antibiotic medication. C. Record review Wound tracker notes dated 12/20/22, and electronically signed by the wound care specialist physician (WP) documented: Start resident on Keflex (antibiotic medication) 500 milligrams (mg) by mouth three times a day for seven days. Recommend skill nursing to monitor wounds. -Review of the December 2022 CPO electronically signed by the resident's primary care physician on 1/3/23 (14 days after the WP ordered antibiotic treatment) revealed no documentation of the order for Keflex being placed or documented in the resident's medication administration record. Primary Care visit note dated 12/27/22, revealed the resident was seen by an attending physician provider. The provider note read in part: Resident has a shallow non-pressure related ulceration of the right anterior calf. He has recurrent large fluid filled blisters that break down to open wounds. This wound has been present for over a week, it is large, last week the legs were very red, the wound was draining and had a foul odor, wound RN (registered nurse) was concerned about infection and started him on Keflex, wound care has been exceedingly difficult. Review of progress notes revealed: Late entered note: IDT (interdisciplinary team) review note entered date 12/29/22 at 10:37 p.m., effective date 12/22/22; written by the NHA (licensed only as a NHA and not as a licensed nurse) read: IDT review of ABX (antibiotic stewardship yielded that patient was not appropriate for recommended course of Keflex based on not meeting McGreer Criteria (provides standardized guidance for infection surveillance activities); absence of four or more present signs of soft skin tissue/wound. Interventions in place: Residents moved to skilled nursing for consistent nursing monitoring of wound and wound care. -There was no documentation of which specific conditions, based on McGreer Criteria, the decision to not provide the resident the prescribed antibiotic was made. Additionally, there was no documentation to indicate which staff participated in the IDT review meeting to make this determination that the prescribed antibiotic was not appropriate for the resident's wounds (see DON interview below for more information). There were no nursing or physician notes about the decision. II. Staff Interview The DON was interviewed on 6/21/23 at 4:20 p.m. The DON reviewed the resident record and was unable to find documentation to support the decision made by the IDT to not provide the resident's prescribed antibiotic medications of the exact IDT members in attendance at that meeting. The DON was not sure if the WP was ever made aware that the order for Keflex antibiotic medication had not ever been administered to the resident when the IDT made the determination that the Keflex was not appropriate. The DON said the facility did not document all discussions with providers and the IDT regarding medical care and treatment decisions. The DON said in an ideal world it would be nice to have all conversations about treatment changes thoroughly documented, but it was not always possible due to the number of discussions held over the course of care.

Based on record review and interviews, the facility failed to consistently provide pain management services for one (#14) of two residents reviewed for pain management out of a 35 sample residents. Specifically, the facility failed to notify the hospice provider in a timely manner for effective care and treatment to keep Resident #14 comfortable and free of pain at the end of her life. Findings include: I. Facility policy and procedure The Hospice program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/22/23 at 5:21 p.m. It documented in pertinent part, When a resident has been diagnosed as terminally ill. The Director of Nursing Services will contact the hospice agency and request that a visit/interview with the resident/family be conducted to determine the resident's wishes relative to participation in the hospice program. In general, it is the responsibility of the hospice to manage the residents' care as it relates to the terminal illness and related conditions, including: determining the appropriate hospice plan of care. Providing medical direction, nursing and clinical management of terminal illness. In general, it is the responsibility of the facility to meet the residents personal care and nursing needs in coordination with hospice representatives, and ensure that the level of care provided is appropriately based on the individual resident's needs. These include: administering prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care. Communicating with the hospice provider (and documenting and communication) to ensure that the needs of the resident are addressed and met 24 hours per day. II. Resident status Resident #14, age 95, was admitted on [DATE] and passed away on 6/21/23. According to the June 2023 computerized physician orders (CPO), diagnoses included chronic kidney disease, chronic pain syndrome and acute chronic diastolic heart failure. According to the 3/30/23 minimum data set (MDS) assessment, the resident was unable to complete a brief interview for mental status (BIMS). The resident received scheduled pain medication. The resident did not receive as needed (PRN) pain medication or non-pharmacological interventions. The resident was receiving hospice care. III. Resident representative interview Resident # 14's representative was interviewed on 6/14/23 at 9:49 a.m. The representative said her mother was in extreme excruciating untreated pain the day prior, on 6/13/23, from 11:00 a.m. and remained in pain up until she left the facility at 6/14/23 at 3:30 a.m. Resident #14 was hollering, removing her clothes and was very uncomfortable. The representative said the nurses on duty continued to increase the resident's current medications without calling the hospice provider to consult with the hospice nurse and request a change in pain medication for more effective pain relief when the current pain medications were not effective. The representative said she asked the nurses throughout the day to call the hospice nurse to get morphine; but the nurse just told the representative they did not have morphine in the facility. The representative said she called the hospice provider herself and found out the hospice provider had provided the facility an emergency box which contained morphine and had been accessible in the facility. The representative said since the resident was on hospice she expected for the facility to contact the hospice provider when needed to keep her comfortable. IV. Record review The comprehensive care plan, initiated on 6/9/23, documented a hospice care focus that revealed the goal of hospice care was to keep Resident #14 comfortable throughout the end of life process through collaboration between hospice and facility nursing staff to provide symptom management and pain control. Interventions include: Assess location, quality and intensity of pain. Hospice staff will obtain physician orders regarding symptom management and pain control. Observe for non-verbal indicators of pain (rubbing, crying, guarding). Report all symptoms to the hospice nurse. According to a nursing note on 6/13/23 at 5:46 p.m. the resident had a good morning and denied pain. Later in the day Resident #14 was very restless and uncomfortable. The nurse gave the resident a PRN (as needed) Ativan and hydromorphone, and the resident began to relax towards the end of the shift. According to a nursing note on 6/14/23 at 5:01 a.m. the resident was restless and agitated at the beginning of the shift. The resident was taking her clothes off, trying to get out of bed, hitting on the wall. Family was present at bedside. Per family the resident has been like this since 11:00 a.m. Continued PRN hydromorphone and Ativan with no relief. The registered nurse (RN) called hospice for evaluation and change in medication, new orders were obtained from hospice to increase hydromorphone to 0.05 milliliters (ml) scheduled every four hours and every hour PRN; and scheduled ativan to 0.5 ml every four hours. The family requested morphine instead of hydromorphone, new orders for Morphine 0.3 ml every four hours scheduled and 0.25ml every hour PRN, discontinued hydromorphone when morphine delivered. Continuing with PRN and scheduled liquid medicine, the resident stabilized around 1:00 a.m. The resident was calmer. According to the June 2023 medication administration record (MAR) the following medications were provided: Hydromorphone (Narcotic meant to treat moderate to severe pain) 4 milligrams (mg) per ml injection syringe (0.25 ml) as needed every hour order date 5/28/23 administered on 6/13/23 at 1:20 p.m. the result was no relief. Lorazepam/ativan (used to treat anxiety) 2mg/ml oral concentrate (0.25 ml) as needed every four hours for 14 days starting 6/12/23 administered on 6/13/23 at 1:36 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) was administered on 6/13/23 at 2:33 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) as needed every hour was administered on 6/13/23 at 6:08 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) as needed every hour was administered on 6/13/23 at 7:10 p.m. the result was no relief. Lorazepam/ativan 2mg/ml oral concentrate (0.25 ml) as needed every two hours starting 6/12/23 was administered on 6/13/23 at 7:10 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) was administered on 6/13/23 at 8:00 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) as needed every hour was administered on 6/13/23 at 9:00 p.m. the result was no relief. Lorazepam/ativan 2mg/ml oral concentrate (0.25 ml) as needed every two hours was administered on 6/13/23 at 9:14 p.m. the result was no relief. Hydromorphone 4 mg per ml injection syringe (0.25 ml) as needed every hour was administered on 6/13/23 at 10:14 p.m. the result was no relief. Lorazepam/ativan 2mg/ml oral concentrate (0.25 ml) as needed every two hours was administered on 6/13/23 at 11:22 p.m. the result was no relief. Hydromorphone 4 mg/ml injection syringe (0.50 ml) as needed every hour start date 6/13/23 was administered on 6/13/23 at 11:30 p.m. the result was no relief. -The pain medications that were administered on 6/13/23 indicated they were not effective/no relief (as indicated by the resident representative as well, see above) and there were no calls to the hospice provider regarding her pain not being alleviated. Hydromorphone 4 mg/ml injection syringe (0.50 ml) as needed every hour start date 6/13/23 was administered on 6/14/23 at 1:00 a.m. the result was effective. Hydromorphone 4 mg/ml injection syringe (0.50 ml) as needed every hour start date 6/13/23 was administered on 6/14/23 at 2:00 a.m. the result was effective. Lorazepam/ativan 2mg/ml oral concentrate (0.25 ml) was administered on 6/14/23 at 2:00 a.m. the result was effective. Morphine (narcotic used to treat moderate to severe pain) oral solution 20 mg/ml (.25ml/5mg) as needed every one hour starting 6/14/23 was administered on 6/14/23 at 4:00 a.m. the result was effective. Morphine oral solution 20 mg/ml (0.3ml/5mg) as needed every four hours was administered on 6/14/23 at 8:00 a.m. the result was effective. Morphine oral solution 20 mg/ml (0.3ml/5mg) as needed every four hours was administered on 6/14/23 at 12:00 p.m. the result was effective. Morphine oral solution 20 mg/ml (0.5ml/5mg) as needed every four hours was administered on 6/14/23 at 4:00 p.m. the result was effective. Morphine oral solution 20 mg/ml (1ml/5mg) as needed every four hours was administered on 6/14/23 at 8:00 p.m. the result was effective. According to the hospice notes from 6/14/23 medications were changed for comfort. -There was no pain assessment documentation for the month of June 2023 including when the resident had a change in condition and her pain level had increased. V. Staff interviews Registered nurse (RN) #5 was interviewed on 6/21/23 at 11:26 a.m. RN #5 said nurses were responsible to call the hospice provider when a resident had increased pain. RN #5 said hospice was available 24 hours a day, seven days a week and would come out to evaluate the resident when they were in uncontrolled pain. RN #5 said the nurse should document all communication with the hospice provider in the resident's record. RN #5 said the facility had an emergency kit from the hospice provider that contained morphine in it. RN #5 said the hospice provider would deliver medication within an hour, when needed, if the medication (morphine) was not available in the emergency kit. The director of nursing (DON) was interviewed on 6/21/23 at 4:26 p.m. The DON said when a resident was on hospice care, the facility nurses monitored the resident for new and increased signs and symptoms of pain and discomfort; the facility nurses were to communicate with the hospice provider to develop a plan to keep the resident comfortable and pain free. The DON said the nurses should call hospice right away when a resident on hospice care experienced uncontrolled pain and document the communication in the resident's medical record. The DON said if a family member asked for a medication change or additional pain medication the nurse should call the hospice provider and ask for a medication change on behalf of the resident or family member. In addition to pain, residents entering the end stages of life can have extreme agitation which could mimic pain to an untrained person. Due to Resident #14's discomfort, the pain medications were changed to add morphine. The first dose of morphine was given on 6/14/23 at 4:02 a.m., per the family's request. The DON said there was not a progress note for 6/13/23 to show communication with the hospice provider when the family told the staff she was in more pain and when the pain medication being administered was ineffective (see above). The DON said the earliest documentation to reflect the resident's increased pain and symptoms was written on 6/14/23 at 5:01 a.m. The DON said documentation should be made in the resident's medical record after each time the nurse called the hospice provider.

Based on record review and interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) prior to the arrival of fire department paramedics, contrary to the medical order set signed by one (#1) out of three residents reviewed for CPR. This failure created a situation for serious harm if not immediately corrected. Record review revealed on [DATE], Resident #1 had expressed and signed, along with his practitioner, a medical order set on a MOST form (medical orders for scope and treatment) to ensure his orders for life-sustaining treatment would be honored by health care professionals. The form read the resident wanted to receive CPR and full treatment - the primary goal to prolong life by all medically effective means. The resident's MOST form was reviewed and the medical orders confirmed the morning of [DATE] at a care conference. Later the same day, at 4:45 p.m., certified nurse aide (CNA) #3 found Resident #1 unresponsive in his room. Registered nurse (RN) #1 was alerted to the resident's change of condition. She said she found the resident with a thready (weak) pulse and his respirations labored. The RN said she notified the former director of nursing (FDON), called 911, and asked the resident's physician (who was in the facility) to assess the resident. The physician said she found the resident unresponsive and breathing normally, but it was difficult to assess the resident's heart; she believed she heard an apical pulse but with his other pulses, it was difficult to tell if he had a pulse. In interviews, both the FDON and certified nurse aide (CNA) #3 said the resident stopped breathing while the FDON, CNA #3, and the physician were in the room and, per the CNA, the physician then called the resident's time of death. Further, RN #1 and the FDON stated that while in the resident's room, the physician directed staff not to begin CPR because the resident was deceased and it would not do any good. The physician disputed she said this, stating the resident stopped breathing and was without pulse just as the paramedics arrived. However, the fire department prehospital care report read, in part: Facility staff stated 'he died a few minutes ago,' and that patient 'was not a good candidate for CPR.' The facility staff stated that the patient had a full code status . Facility staff stated that the patient had been down approximately eight minutes without CPR . The report documented the resident was assessed as unconscious and unresponsive; pupils were fixed and dilated, skin was warm, pale and dry. There was no rise and fall of the chest and the patient was not breathing. Paramedics initiated CPR until further efforts were deemed futile and termination of resuscitation was granted by a local hospital. Findings include: IMMEDIATE JEOPARDY I. Findings of immediate jeopardy Based on record review and interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) prior to the arrival of fire department paramedics, contrary to the medical order set signed by one (#1) out of three residents reviewed for CPR. This failure created a situation for serious harm if not immediately corrected. Record review revealed on [DATE], Resident #1 had expressed and signed, along with his practitioner, a medical order set on a MOST (medical orders for scope and treatment) form to ensure his orders for life-sustaining treatment would be honored by health care professionals. The form read the resident wanted to receive CPR and full treatment - primary goal to prolong life by all medically effective means. The resident's MOST form was reviewed and the medical orders confirmed the morning of [DATE] at a care conference. Later the same day, at 4:45 p.m., certified nurse aide (CNA) #3 found Resident #1 unresponsive in his room. Registered nurse (RN) #1 was alerted to the resident's change of condition. She said she found the resident with a thready (weak) pulse and his respirations labored. The RN said she notified the former director of nursing (FDON), called 911, and asked the resident's physician (who was in the facility) to assess the resident. The physician said she found the resident unresponsive and breathing, but it was difficult to assess the resident's heart; she believed she heard an apical pulse but with his other pulses, it was difficult to tell if he had a pulse. In interviews, both the FDON and certified nurse aide (CNA) #3 said the resident stopped breathing while the FDON, CNA #3, and the physician were in the room and, per the CNA, the physician then called the resident's time of death. Further, RN #1 and the FDON stated that while in the resident's room, the physician directed staff not to begin CPR because the resident was deceased and it would not do any good. The physician disputed she said this, stating the resident stopped breathing and was without pulse just as the paramedics arrived. However, the fire department prehospital care report read, in part: Facility staff stated 'he died a few minutes ago,' and that patient 'was not a good candidate for CPR.' The facility staff stated that the patient had a full code status .' Facility staff stated that the patient had been down approximately eight minutes without CPR . The report documented the resident was assessed as unconscious and unresponsive; pupils were fixed and dilated, skin was warm, pale and dry. There was no rise and fall of the chest and the patient was not breathing. Paramedics initiated CPR until further efforts were deemed futile and termination of resuscitation was granted by a local hospital. On [DATE] at 6:46 p.m. the nursing home administrator (NHA) was notified that the facility's failure to immediately initiate CPR for Resident #1 created a situation for serious harm if the situation was not immediately corrected. II. Facility plan to remove immediate jeopardy On [DATE] at 5:40 p.m. the NHA provided the following plan to remove the immediate jeopardy situation. Plan to remove immediate Jeopardy. This plan is submitted, as the facility's credible allegation of compliance and this facility will be in substantial compliance with all Federal certification requirements. Summary of incident: Resident #1 passed away while in the facility care. CPR was not performed when he was found not breathing and to not have a pulse despite having an advanced directive to perform resuscitation. Facility response: 1. Upon notification of alleged deficient practice on [DATE], all current residents [cor] status [was] audited by the NHA, and DON and reviewed once more on [DATE]. (The [DATE] audit revealed a resident the facility did not have on the full CPR advance directive list. This was rectified on [DATE]) All licensed staff on-shift were reeducated by DON and MDS (minimum data set) coordinator [MDSC] identifying current residents [cor] status and CPR provisions outlined in Federal tag 678. On [DATE] NHA notified medical director of the alleged deficient practice of the attending physician for Resident #1 and is in contact with the provider regarding the incident. The facility CPR policy was revised on [DATE] by (the) community executive leadership team. (see revised policy below) (Facility name) policies and procedures are based on current standards of practice. In addition to current standards of practice, the facility is educating staff on proper CPR and Code Status, as outlined in F-678. Educators for the facility are the DON and MDSC who hold active Basic Life Support certificates, through the American Heart Association. Educators provide written and in-person training to employees pertaining to the CPR provisions, crash carts, and as needed clinical education. Employees will attest to compliance of trainings and understanding the content of in-service forms and individualized educations. Training on the MOST form will be completed by the NHA using Colorado Advance Directive Consortium (CADAC) information. All licensed staff and contracted licensed agency staff will be trained with [DATE] written and in-person training. A mock CPR training, which will include notification to staff on the mock incident, the code status, retrieval of crash cart, and successful CPR, is scheduled for [DATE] at 2:00 p.m. for all licensed staff by the facility educators. All licensed and certified staff are currently being reeducated on CPR provisions outlined in Federal tag 678 - CPR, including following code status, and steps in responding to individuals in distress. Education was provided on February 22, 2023 at 6:50 p.m. and will be completed by [DATE]. Education was provided by DON, MDS Coordinator, and NHA. Education was provided at 6:50 p.m. on [DATE]. Licensed nursing staff education will be completed by [DATE]. CPR training will continue to be a condition of employment for licensed staff and will be renewed accordingly by the renew date. CPR certifications are required by contract agencies and are monitored by NHA when reviewing contracts and assigned staff. Medical Director provided education to the attending physician for Resident #1 on [DATE] regarding the facility policy on Advance Directives and adhering to Advance Directives. Medical Director will provide annual Advance Directive education to all facility providers beginning [DATE]. 2. Updated CPR policy (presented by the NHA on [DATE] at 4:00 p.m. following revisions to the policy presented 2:58 p.m. that had instructed staff to retrieve the automatic external defibrillator (AED) as interview (interim DON on [DATE] at 5:00 p.m.) revealed the facility did not have an AED and that had instructed untrained staff rescuers to provide chest compressions to victims of cardiac arrest) read in pertinent part: Sudden cardiac arrest (SCA) is a loss of heart function due to abnormal heart rhythms (arrhythmias). Cardiac arrest occurs soon after symptoms appear. It is a leading cause of death among adults. A 'heart attack' refers to impaired blood flow to the heart which leads to damage of the heart muscle. A heart attack can cause sudden cardiac arrest. Typically heart attacks are less sudden than SCA. Victims of cardiac arrest may initially have gasping respirations or may appear to be having a seizure. Training in BLS (Basic Life Support) includes recognizing presentations of SCA. The chances of surviving SCA may be increased if CPR is initiated immediately upon collapse. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless; It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR; or There are obvious signs of irreversible death (e.g., rigor-mortis). If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. Licensed Nurses are responsible for coordinating the rescue effort and directing other team members during the rescue effort. All of whom have received training and certification in CPR/BLS. Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If cardiac arrest is likely begin CPR: Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the DNR or code status of the individual. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Chest compressions: Follow initial assessment, begin CPR with chest compressions. All trained rescuers should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Continue with CPR/BLS until emergency medical personnel arrive. III. Removal of immediate jeopardy Based on the facility's plan as set forth above, the immediate jeopardy situation was removed at 5:40 p.m. on [DATE]. However, deficient practice remained at a G level, isolated, actual harm. FACILITY FAILURES I. MOST form The Colorado Advance Directives Consortium [DATE], retrieved from https://www.coloradoadvancedirectives.com on [DATE] at 12:26 p.m. revealed in pertinent part: . [W][NAME] presented with a MOST, healthcare providers MUST: follow the orders as written, or obtain consent from (a) patient or authorized decision maker to change the orders, or promptly and safely transfer the patient to a provider who will follow the orders. If an individual has executed a CPR directive on his or her own behalf, in any manner or on any form including a MOST, a Healthcare Agent, Guardian, or Proxy-by-statute may not revoke it under any circumstances. II. Resident #1 A. Resident status Resident #1, over age 65, was admitted on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included stroke, right side weakness, speech disorder, heart disease, high blood pressure, neuropathy, osteoporosis, dysphagia (swallowing difficulties), elevated serum lipids, and internal cardiac defibrillator placement. The resident expired at the facility on [DATE]. His death certificate, dated [DATE], revealed the primary cause of death as cardiac arrest, unspecified atrial fibrillation and essential primary hypertension. The [DATE] minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 8 out of 15. He required two-person assistance with bed mobility, transfer, dressing, toileting and personal hygiene. He needed set up assistance only with meals and mobility in the room and corridor did not occur. B. Medical orders for life-sustaining treatment A review of the Resident #1's record revealed a MOST form was signed upon admission to the facility, which indicated the resident wanted cardiopulmonary resuscitation (CPR) (Box A) and Medical Interventions to include Full Treatment (Box B). The resident signed the MOST form on [DATE] and the nurse practitioner (NP) signed the MOST form on [DATE]. The MOST form read in pertinent part, Emergency medical personnel, a healthcare provider, or healthcare facility shall comply with an adult's properly executed MOST form that has been executed in this state or another state and was apparent and immediately available. If a healthcare provider considers these orders medically inappropriate, she or he should discuss concerns with the patient or surrogate legal decision maker and revise orders only after obtaining patient or surrogate consent. A review of the resident's [DATE] and [DATE] computerized physician orders revealed no evidence of a Do Not Resuscitate (DNR) order and no evidence of the medical orders found in the resident's MOST form; the advanced directive section was left blank. A review of the [DATE] care conference notes revealed Resident #1's MOST form was reviewed during the care conference with the resident in attendance. C. Documentation and interview of events on [DATE] 1. Documentation A review of the [DATE] care conference notes, held at 11:21 a.m., revealed the resident's MOST form was again reviewed during the care conference. The care conference sign in sheet for the [DATE] care conference listed Resident #1's two daughters as present for the care conference via phone. A review of the [DATE] clinical note entered at 7:03 p.m. revealed an unidentified certified nurse aide (CNA) notified registered nurse (RN) #1 that Resident #1 was unresponsive when they attempted to serve the meal tray at dinner. RN #1 came in to assess the patient and noted it was difficult to locate a pulse, his breathing was normal, and he appeared pale in color. RN #1 notified the resident's physician who was in the facility. An unidentified staff member called 911. Paramedics attempted resuscitation for approximately 30 minutes without a response. A physician from a local hospital pronounced Resident #1's death at 6:02 p.m. The resident's physician called and notified the family of the resident's passing. Review of the [DATE] resident physician note read in pertinent part, Resident #1 was seen emergently for unresponsiveness. -Staff reported that he was in his usual state of health throughout the day and had worked with therapy earlier in the afternoon. When the certified nurse aide (CNA) went in to give him his dinner tray, he was unresponsive. The CNA called the nurse who then came to get me to assess him. -Upon arrival in his room, he was still breathing. He was not diaphoretic (sweating heavily) or pale. He did not respond to voice or sternal rub. Nursing called 911 at this point as he was full COR (wanting CPR). Attempts to get a radial, carotid, femoral, or apical pulse were unsuccessful; he was on oxygen but they could not get a pulse ox reading. As the (emergency medical technicians) EMTs arrived, he stopped breathing. -A short course of resuscitation was done which was unsuccessful. He was pronounced dead by a physician from a local hospital at 6:02 p.m. The physician called his daughter to inform her of his death. -The note also revealed the resident's death was not unexpected due to his recent stroke, (recent) COVID-19 infection, and decline in functional status over the past week. Review of the [DATE] medical director (MD) note revealed the MD reviewed Resident #1's change of condition. No additional notes were included. D. Interview 1. The NHA was interviewed with the interim director of nursing (IDON) on [DATE] at 5:00 p.m. and [DATE] at 10:36 a.m. and 12:10 p.m. about the events and follow up to the events on [DATE]. The NHA said she was not in the building at the time Resident #1 had a change in condition, but she was aware when Resident #1 passed away and had reviewed the documentation the following day with the DON and central office. She said the medical director (MD) reviewed the situation as well and she (the NHA) called the family. She said RN #1 was the RN who responded to the resident during meal time; a CNA was passing trays and RN #1 went into Resident #1's room because of a change of condition. She said the resident was assessed and was breathing normal([NAME]) and RN #1 asked the CNA to stay in the room. RN #1 notified the former director of nursing (FDON) and the physician that Resident #1 had a change of condition; the physician went to the Resident #1's room and the FDON went to the nurses' station and directed the paramedics to Resident #1's room. RN #1 called 911. The NHA said the physician then took over the direction of Resident #1's care and was in the room with the resident. She said 911 was made aware of his full code status and they did a short course of resuscitation which is standard. This resident had a pacemaker and was pronounced dead at 6:02 p.m. and the physician called the family. The NHA said she spoke with the resident's physician, the FDON and the MD. The NHA stated that the resident physician's reason for not doing CPR was that the only person not to do CPR was the nurse because the paramedics arrived at that time and started CPR. The NHA said she was not certain, but thought the FDON thought CPR should have been started. The NHA stated the MD talked through the events and reviewed documentation and the staff appeared to follow facility protocol. (However, see below: Review of facility policy and expectations) 2. The resident's physician was interviewed by phone on [DATE] at 10:46 a.m. She said she was in the facility the day Resident #1 passed away and RN #1 came to get her because Resident #1 had a sudden change of condition. She said Resident #1 was unresponsive to touch and name, and that CNA #3 said the resident would not wake up when she gave him his dinner tray. The physician said the resident was breathing normally, and was not pale or sweaty. She said the resident did not respond to voice or a sternum rub, and he was moving air while she was listening to his lungs. It made it difficult to assess his heart. She believed that she could hear an apical pulse but with the others (pulses), it was difficult to tell if he had a pulse. He was on his oxygen and the physician could not get an accurate pulse oximeter reading. She said as the paramedics were coming into the building, Resident #1's breathing matter changed. The paramedics stepped in and started the resuscitation and she stepped out to call his family about the change of condition. The physician said she asked the staff to call 911 because the resident was full cor and still breathing. She said she did not direct staff to not do CPR. She thought if they started CPR, they would affect his breathing; it was a judgment call at that time and they would continue to monitor him until the paramedics came. She told the paramedics the resident was on a decline and he was a full cor, was admitted after a stroke, that initially the resident had done very well and then had declined. She then told the paramedics what she observed when she got into the resident's room. She said she did not know if resuscitating him was going to be successful but CPR was his wish. She said the facility should perform CPR based on the MOST form. She said the resident was breathing while she was in the room and when it became inefficient. She said he stopped breathing and he was without a pulse just as the paramedics arrived. She said she was in the room the entire time and did not step out until the paramedics arrived. The physician said she did not know if her CPR card was current, but she knew how to perform CPR. III. Failure to follow Resident #1's medical orders for CPR. Staff interviews and the fire department prehospital report conflicted with the resident's physician's note, and interviews indicated the facility had failed to follow Resident #1's medical orders to provide cardiopulmonary resuscitation (CPR) prior to the arrival of fire department paramedics. A. Staff interviews 1. RN #1 was interviewed by phone on [DATE] at 1:35 p.m. about the events on [DATE]. She said CNA #3 came to her and said Resident #1 was not responding, so RN #1 went back Resident #1's room, and observed he was pale, clammy and not responding to his name. RN #1 said she had assessed Resident #1's pulse, felt a thready (weak) pulse, yelled out Resident #1's name, did a sternal rub and Resident #1 gave some kind of response but not an alert response. RN #1 said Resident #1 had some respirations that were labored. She did not count his respirations and pulse but knew they had to respond quickly. She said she did take his vitals in the morning, and he was speaking and normal at that time, with nothing unremarkable observed and nothing that indicated any kind of condition change. RN #1 said she went back to the nurses' station because Resident #1 was a full code and she told CNA #3 to stay with Resident #1. RN #1 said she also told the resident's physician that Resident #1 wasn't responding. RN #1 said she did not remember what time she called 911, but she called 911 right away and told the 911 operator the staff were going to begin CPR and she went right back down to the room. RN #1 said her first instinct was to do CPR right away but the resident's physician pulled her to the side and said to RN #1 there was no need to do CPR as Resident #1 was deceased . RN #1 said she did not know what to say in response to the physician at that time; you do not excuse a doctor's order and what the doctor was saying. RN #1 said she was not going to fight a doctor but she would have done CPR, and followed the resident's instructions (medical orders) but she did not perform CPR. RN #1 said CNA #3 did not do CPR because she was waiting for RN #1's instruction to begin it. RN #1 said the resident's physician intercepted the paramedics on the way to Resident #1's room but she did not hear the conversation. RN#1 said the patient's wish was to have CPR due to the [MOST] form the resident signs. 2. CNA #3 was interviewed by phone on [DATE] at 2:25 p.m. about the events on [DATE]. She said earlier in the day, Resident #1 was fine, and she went to take him his dinner tray and he appeared to be sleeping. She said she tried to wake him up but she could not, and she hollered at the other CNA to go get RN #1. RN #1 assessed Resident #1 while CNA #3 was in the room. CNA #3 said Resident #1 had labored breath sounds. CNA #3 said RN #1 was unable to find a pulse so RN #1 went to get the resident's physician. She said the physician and the former director of nursing (FDON) came in to Resident #1's room. CNA #3 said at that time she was in the room but was over by the door and during that time the resident stopped breathing. CNA #3 said the resident's physician then called time of death for Resident #1. CNA #3 said no one did CPR and RN #1 found out Resident #1 was a full code and relayed the message to the resident's physician while they were in Resident #1's room. CNA #3 said the paramedics showed up after about 5 minutes or less. CNA #3 said the resident's physician spoke to the paramedics, and the paramedics asked if CPR had been done and the physician said no. CNA #3 said she was not in the room with the paramedics while they performed CPR. CNA #3 said she was not told to do CPR by the resident's physician and did not perform CPR. CNA #3 said the former director of nursing (FDON) was present in Resident #1's room at this time. 3. The FDON was interviewed by phone on [DATE] at 4:27 p.m. about the events on [DATE]. The FDON stated she was in her office when RN #1 came into her office and said there was a crisis in Resident #1's room, and RN #1 said she couldn't get Resident #1's pulse. The FDON said she went to Resident #1's room and the resident's physician was there and the physician said she did not want anyone doing CPR because it would not help. The FDON said when she got to Resident #1's room he was cold to the touch and not breathing. She said she observed the resident's physician attempting and unable to feel a pulse and the FDON said the physician checked the apical, femoral, and there was no pulse. She said Resident #1 was barely breathing and then he stopped breathing altogether. The FDON said the resident's physician declared a time of death, but the facility did not document when the physician called the time of death. The FDON said she would have absolutely performed CPR. The FDON said she heard the resident's physician tell CNA #3 to not perform CPR. The FDON said CPR should have been started when there was no pulse. The FDON said the physician told her told it would not do any good to do CPR. The FDON said from this time until the paramedics arrived, the physician sat in the resident's room, saying she did not want CPR done and that CPR would not do any good, and CPR was not performed. The FDON said RN #1 was at the nurses' station when paramedics arrived. The FDON stated the paramedics did CPR because Resident #1 was a full code and she said the facility staff should have also performed CPR. The FDON said she spoke with the nursing home administrator (NHA) and told the NHA that the facility staff should have performed CPR and the incident should be investigated. The FDON said the NHA said she would investigate. The FDON said she also spoke to the medical director (MD), and he agreed that CPR should have been started immediately and said he would talk to the resident's physician. 4. The social services director (SSD) was interviewed by phone on [DATE] at 12:18 p.m. She said she was the person that handles the care conferences and got involved with the MOST process when it was time for a care conference. She said a full code was when resuscitation was attempted and every means necessary was provided to the resident. She said a MOST form should never not be followed; you always followed that MOST form. She said the facility reviewed Resident #1's MOST form and she thought he was a full code and if so, CPR should have been given to him. B. Prehospital report The fire department prehospital care report was provided on [DATE] at 8:08 a.m. by the local fire department who responded to the 911 call. The report revealed the call type as cardiac arrest and possible dead on arrival (DOA) and listed the following timeline: -Call received at 5:23:54 p.m. -Dispatched and enroute at 5:25:11 p.m. -On scene at 5:30:03 p.m. -At resident at 5:33:03 p.m. The report revealed, Upon arrival, the paramedics were met by facility staff outside of the patient's room. Facility staff stated 'he died a few minutes ago,' and that patient 'was not a good candidate for CPR.' . The facility staff stated that the patient had a full code status .' Facility staff stated that the patient had been down approximately eight minutes without CPR, had been on isolation precautions and provided paperwork regarding the patient's medical history and additional information. The report revealed the resident was assessed as unconscious and unresponsive; pupils were fixed and dilated, skin was warm, pale and dry. There was no rise and fall of the chest and the patient was not breathing. All resuscitative efforts were exhausted and further efforts were deemed futile and a local hospital was contacted for termination of resuscitation. Termination was granted and the time of death was listed as 6:02 p.m. IV. Facility failure to follow its policy and expectations regarding CPR A. Facility policy and Admission packet for Residents The Emergency Procedure-Cardiopulmonary Resuscitation (CPR) policy, revised February 2018, was provided by the nursing home administrator (NHA) on [DATE] at 3:15 p.m. It read in pertinent part: If an individual (resident, visitor or staff member) was found unresponsive and not breathing normally, a licensed staff member certified in CPR/BLS (basic life support) would initiate CPR unless: -It was known that a do not resuscitate (DNR) order that specifically prohibited CPR and/or external defibrillation existed for that individual. -There were obvious signs of irreversible death (such as rigor mortis). If the first responder was not CPR-certified, that person would call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrived. If an individual was found unresponsive, they were briefly assessed for abnormal or absence of breathing. If sudden cardiac arrest was likely, CPR should be started. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest and continue with CPR/BLS until emergency medical personnel arrived. The facility Admission packet for residents which contained a resident handbook was provided by the NHA on [DATE] at 1:00 p.m. It revealed in pertinent part under Advance Directives: It is the policy of (facility name) to ensure each resident has the right to . formulate an advance directive. -The facility will follow the (facility name) guidelines and policy for CPR administration in accordance with accepted guidelines of the American Heart Association, the American Red Cross, or other nationally recognized subject matter experts concerning CPR. -Assist the resident with securing standardized forms such as MOST .and assist with review of materials. -Educate staff regarding advance directives, resident's rights, and the importance of being aware of the resident's wishes. -Copies of the signed advance directives will become part of the medical record and be accessible to other healthcare providers for continuity of care communication as requested. B. Failure to follow facility policy and meet expectations for CPR 1. See staff interviews

Based on observation, interview and record review the facility failed to ensure the residents' environment remained as free from accidents hazards as possible for two (#3 and #4) of four residents reviewed for falls out of five sample residents. Specifically, the facility failed to: -Provide effective monitoring and supervision for safety of Resident #3 and Resident #4. -Provide/install anti-roll backs on Resident #3's wheelchair to prevent rolling. The facility failed to ensure Resident #4 had sufficient supervision with her risk of falling and leaning in her wheelchair. As a result, the resident fell face down onto the floor which resulted in Resident #4 having to be transferred to the emergency room , where she received treatment for a lacerated lip, in which they closed the wound with liquid adhesive and steri-strips to her right hand. Findings include: I. Facility policy and procedure The Fall and Fall Risk, Managing policy, dated 2001, was received from the nursing home administrator (NHA) on 2/27/23 at 12:00 p.m It read in pertinent part: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him.herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. Medical factors that contribute to the risk of falls include: arthritis, neurological disorders and balance and gait disorders. Resident-centered approaches to managing falls and fall risk: Will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls, identify several possible interventions, and if falling recurs despite initial interventions, staff will implement additional or different interventions. Monitoring subsequent falls and fall risk: will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling, if the resident continues to fall, will re-evaluate the situation and whether it is appropriate to continue or change current interventions. The Assessing Falls and their Causes policy, dated 2001, was received from the NHA on 2/27/23 at 12:00 p.m It read in pertinent part: The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. Obtain and record vital signs as soon as it is safe to do so. If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately. Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall, and will document findings in the medical record. Document any observed signs or symptoms of pain, swelling, bruising, deformity, and/or decreased mobility, and any changes in level of responsiveness/consciousness and overall function. II. Resident #4 A. Resident status Resident #4, age 83, was admitted to the facility on [DATE]. According to the February 2023 CPO diagnoses included Alzheimer's disease, Parkinsonism, depression, generalized anxiety disorder, and hypertensive. The 1/23/23 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 dependent for care and required extensive assistance of two or more people for bed mobility, transfers between surfaces, dressing, toileting; and one person assistance with locomotion on and off the unit, eating and personal hygiene. The resident was unable to walk in their room or in the corridor. B. Resident representative interview The resident's representative was interviewed on 2/27/23 at approximately 1:30 p.m. She said she had been notified at 7:53 p.m., that her mom had fallen and was on her way to the hospital. She said her father had let the facility staff know Resident #4 was ready for bed as she was sleepy. She said the facility staff said another resident had distracted the staff and they did not get to the resident timely, and she fell . She said the fall happened at 7:00 p.m. The facility knew the resident could not be left alone, as she would lean forward. She said a new wheelchair was received to help with her positioning. C. Record review The comprehensive care plan for falls initiated on 3/29/22 documented that Resident #4 was at risk for falls. Interventions included instructing the resident to use handrails and assist devices to maintain balance, reporting episodes of dizziness, moving the resident around the unit in a wheelchair, footwear to fit properly and have non-skid soles, place the call light within reach, and to respond promptly to calls for assistance. The progress notes documented the resident had experienced two falls within the last six months. The notes were as follows: The 9/27/22 note at 5:08 p.m. documented an unwitnessed fall. The nurse was notified by the certified nurse aide (CNA) that the resident was found half way out of bed with her upper body facing down on the right side of the bed and her lower body was still in the bed. The resident suffered an abrasion to the left side of the neck and a bruise under the left eye. The 1/28/23 note documented an unwitnessed fall. The resident was found by a CNA on the floor next to the wheelchair face down and blood pooling on the floor from the resident's nose and mouth. The nurse performed vital signs and a neurological check, and the resident was transferred to the hospital. The resident returned from the hospital. The resident's lip was glued, an x-ray was completed with no fractures and steri-strips applied to her right hand. D. Interview The interim director of nursing (IDON) was interviewed on 2/27/23 at 2:31 p.m. The IDON reviewed the resident's record. She said the resident did exhibit a fall which resulted in her going to the hospital for an injury. She said the resident leaned forward and fell . She said interventions for the resident included to not leave her alone unattended. A new wheelchair was obtained from the hospice provider which also assisted with her positioning. The IDON confirmed the resident had not been assessed for falls since admission to the facility. The IDON was interviewed a second time on 2/27/23 at approximately 5:00 p.m. The IDON said the residents were supposed to be assessed for falls quarterly. She said the regional office had informed her that the residents were to be assessed quarterly. III. Resident #3 A. Resident status Resident #3, age 88, was admitted to the facility on [DATE]. According to the February 2023 computerized physician orders (CPO) the diagnoses include Parkinson's disease, seizure disorder, dementia, and anxiety disorder. The 12/11/22 MDS assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of one out of 15. The resident requires extensive assistance of two or more people with bed mobility, transfers between surfaces, dressing, and toileting. The resident requires extensive assistance of one person with locomotion on and off the unit with a wheelchair and personal hygiene. B. Observation On 2/23/23 at 1:42 p.m., the resident was sitting in his wheelchair. He did not have anti-tip bars on his wheelchair. The resident was leaning forward from waist down in his chair, reaching out. On 2/23/23 at 4:20 p.m. the resident continued to sit in his wheelchair. The resident had a blanket around his legs, he was trying to get it off as it was tangled around his legs. At 8:45 a.m., the resident self propelled himself from his dining room table. He continued to not have the anti-tip bars on his wheelchair. At 9:10 a.m., the resident was leaning forward in his chair. There were other residents near the resident, however, no staff in the dining room at that time. At approximately 5:00 p.m., the interim director of nurses (IDON) observed his wheelchair and she confirmed anti-tip bars were not on the back of his wheelchair. C. Record review The comprehensive care plan for falls initiated on 3/31/22 identified that Resident #3 was at risk for falls due to poor sitting posture, decreased bed mobility, he leaned to the side when up in the wheelchair. He leaned forward in the wheelchair from the waist down attempting to pick something up and the resident did not want staff to assist him to sit up straight. Interventions included installing anti roll backs on the wheelchair, using a mattress with bolsters for positioning, replacing fall mat with a beveled edged mat next to the bed, frequent checks, encourage call light use, redirection adjusting stimulation in the environment, assisting to desired location, reminding the resident to call for assistance before standing or walking without help, getting out of bed to walk, or going to the bathroom. The progress notes documented the resident had experienced seven falls within the last six months. The notes were as follows: Fall #1 The 9/17/22 documented the resident was found on the floor in the dining room with his wheelchair behind him and the table in front of him. The resident was in a reclining position on his right side. Fall #2 The 9/25/22 note documented the nurse was called to the TV lounge to assess the resident for fall. The resident was found on his left side curled up in a fetal position. The resident was found to have blood to mouth and left forehead. Upon assessment, resident noted to have a significant raised area to left forehead with laceration in the center, some bleeding present. The resident's oral cavity was assessed and the resident had bitten his tongue. The resident was sent to the hospital. The resident returned from the hospital with dry dressing applied to left forehead. Fall #3 The 12/31/22 progress note documented, the resident was on follow up related to a fall. The resident remained on neurological checks. -The resident's medical record failed to document any further information on when the fall occurred and any injuries. The facility failed to have an investigation on the fall. Fall #4 The 1/24/23 note documented the resident was on the floor mat on his buttocks beside the bed. The resident said his bottom was slightly sore. The interdisciplinary team (IDT) note from 1/26/23 documented an IDT review of the recent fall. It documented the care plan was being followed at the time of the incident. Interventions included every morning visual checks to check if the resident was awake and if he was awake to ask him if he was ready to get up. Fall #5 The 2/14/23 nursing note documented that the resident had an unwitnessed fall in the dining room. The resident was found sitting on the floor. He was able to answer questions and denied pain. The resident continued to lean forward in his chair to adjust sock. No injuries. Fall #6 The nursing note dated 2/14/23 at 6:30 p.m., documented the nurse found the resident sitting on his bottom on the floor next to his wheelchair with his back resting against the wheelchair around 6:25 p.m. The resident was unable to answer what happened and denied hitting his head. The resident was assessed by a registered nurse (RN) supervisor to perform range of motion (ROM), he was at baseline, no apparent injuries. Fall #7 Nursing note from 2/15/23 documented a certified nursing aide (CNA) notified the nurse at 7:30 a.m. that the resident was on the floor in his room. The resident was on the floor mat on both knees facing the bed with his head resting on the bed. The note documented the RN who was the IDON did a head to toe assessment. No injuries. The medical record showed the resident had a fall assessment completed on admission on 3/17/21 which showed the resident had a score of 16 which indicated the resident was at risk for falls. Otherwise the resident had not had a fall assessment. -The facility failed to show the resident's interventions were evaluated for effectiveness. D. Interviews The IDON was interviewed on 2/27/23 at 2:31 p.m. The IDON reviewed the resident's medical record. She reviewed the resident's fall investigations, which documented the same information as the progress notes. She said the fall on 12/20/22 she was unable to find an investigation. The IDON said the falls were reviewed in the daily meetings and also with a IDT meeting, however, the record only showed one IDT meeting progress note on 1/26/23. She said the IDT meeting was to discuss the fall and to determine if the approaches were appropriate. The IDON said according to the care plan, the resident was to have anti-tip bars on the back of the wheelchair, and the resident was referred to therapy. She said although the resident was cognitively impaired, she thought the call light within reach and encouraging the resident to use call light was appropriate. She said the resident had a lot of fall interventions in place. A medication review was requested, however, had not occurred after the 2/15/23 fall. The IDON said a fall risk (fall investigation was not completed for the fall on 2/13/23. A care conference was scheduled on 2/24/23 however, was canceled as the social worker was out of the office. It had been rescheduled for 3/1/23. The IDON said the last time the resident was assessed for falls was 12/8/21. She said the resident was only assessed for falls at admission. The director of rehabilitation (DOR) was interviewed on 2/27/23 at 4:30 p.m. The DOR reviewed the record and said the resident had not been referred to therapy. She said the resident had not been assessed by therapy for the anti-tip bars as it was not covered by insurance.

Based on record review and interview, the facility failed to ensure in-service training for five of five certified nurse aides (CNAs) reviewed, in their annual training, no less than 12 hours per year contained dementia management training. Specifically, the facility failed to ensure in-service training records reviewed for five CNAs #1, #2, #3, #4, and #5 had dementia management training in their required 12 hours of annual training. Findings include: I. Training review Five nurse aides (#1, #2, #3, #4, #5) were reviewed for the annual required dementia management training. The nursing home administrator (NHA) was unable to provide any requested dementia management training records for five of the five CNAs requested records. II. Record review The Resident Census and Conditions form was requested from the NHA on 2/23/23 at 9:59 a.m. which contained the number of residents in the facility and the number of residents with a diagnosis of dementia. The information was not provided during the survey. The NHA was also requested to provide the facility's dementia care education training notes but she said she did not have any education to provide. III. Interview The nursing home administrator (NHA) was interviewed on 2/27/23 at 9:58 a.m. She said the facility did not have any records of dementia training for the five CNAs requested records. She said she knew the yearly 12 hour required training should contain dementia management training. She said she could provide education formats for other required training but not for dementia care. She said she knew CNAs needed to have ongoing training to make sure their skills were up to date and to ensure the residents were cared for properly. She said if she could find any documentation she would provide proof of education during the survey. (No documentation was provided by the exit date of 2/28/23) She said the facility did not have a staff development coordinator (SDC) to provide training. She said over the last few months some upper management had quit working at the facility who had provided different types of training. She said in the future during 2023 either she or the assistant director of nursing (ADON), who was filling in also as a director of nursing (DON) until a new DON was hired, would be training the staff in all the required training.

Based on record review and staff interview the facility failed to have in effect a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs in order to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect for the one local area hospital. Findings include: I. Record review During the survey from 2/21/23 to 2/28/23, the hospital transfer agreement was requested from the nursing home administrator (NHA) via email on 2/23/23 at 4:47 p.m. -The facility was unable to provide a written agreement for the one area hospital. II. Interview The NHA was interviewed on 2/28/23 at 12:10 p.m. She said the facility used one area hospital often, and sometimes other local hospitals were utilized to transport residents. She said she could not provide a hospital transfer agreement because the facility did not have any agreements or contracts with any hospitals about transporting residents. She said I assume the facility may have had contracts when the facility opened about 20 or [AGE] years ago, but the facility has no current hospital contracts or agreements.

Based on record review and staff interviews, the facility failed to implement policies and procedures to thoroughly screen staff to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property, prior to a staff member providing direct care to residents. Specifically, the facility failed to: -Complete employee background checks before the facility allowed staff to work with residents in the facility, which included registered nurse (RN) #4; -Investigate concerns about registered nurse (RN) #4's background check; -Prevent RN #4, who had a suspended nursing license in another state, from providing direct patient care in the facility. The failure to have policy and procedure to screen employees prior to providing care to residents had a facility wide impact. Findings include: I. Facility policy The Abuse Prevention Program policy, revised 10/15/22, was provided by the nursing home administrator (NHA) on 2/28/23 at 10:15 a.m. It read in pertinent part, The policy of (facility name) is zero tolerance of any form of abuse, neglect, or exploitation. Screening of Staff Pre-employment screening will be completed on all post-offer applicants, to include: Criminal history check, background check, reference check from previous employers, professional licensure, certification or registry check as applicable. The Recruitment Process Steps for HR (human resources), 3/20/22 and updated with a page heading during survey on 2/28/23, was provided by the NHA on 2/28/23 at 10:15 a.m. It read in pertinent part, Background expectations Includes referencing and pre-employment steps at or around (the) offer. Use the referencing tool, and upload to the candidate file once completed. Begin (background check company name) process - manage the (background company name) dashboard by referencing (the) day to ensure (the) process is advancing. Address any issues immediately to ensure there are limited delays if any. Follow State and county pre-employment requirements. For example, TB (tuberculosis testing) fingerprinting, state registry checks, FBI (Federal Bureau of Investigation) checks, etc. (etcenterra). II. Record review A. RN #4 background information RN #4 entered background information into the background company's website on 1/1/23. On 1/17/23 the facility was notified by the background company of the following problems with the prospective employee's information. -Professional license had a discrepancy. A client review was required. -Adult abuse registry revealed additional information was required. -Self adjudication revealed this did not meet company standards. -RN #4 did not provide correct past employment history dates correctly according to the human resource director (HRD). -RN #4 did not provide a correct RN license number according to the HRD. B. RN #4's timecard RN #4's timecard was provide by the NHA on 2/27/23 at 5:05 p.m. RN #4 worked in the facility prior to his background check being completed. He was in the facility three times for orientation without direct patient care and eight times he worked on a medication cart and provided direct care to residents on the following dates: -On 1/5/23, 1/13/23 and 1/17/23, RN #4 had orientation in the facility but did not have direct patient care. On the following dates RN #4 worked having direct patient care and had access to the medication cart: -On 1/12/23 from 5:50 p.m. until 12:00 a.m. -On 1/13/23 from 10:00 p.m. until 1/14/23 at 6:16 a.m. -On 1/16/23 from 6:04 p.m. until 10:30 p.m. -On 1/19/23 from 5:56 p.m. through 1/20/23 at 6:21 a.m. -On 1/21/23 at 6:39 p.m. through 1/22/23 at 7:01 a.m. -On 1/23/23 from 5:59 p.m. until 1/24/23 at 6:49 a.m. -On 1/26/23 from 5:15 p.m. through 1/27/23 at 7:47 a.m. -On 1/27/23 from 5:46 p.m. through 1/28/23 at 8:08 a.m. III. Interviews The NHA was interviewed on 2/23/23 at 10:23 a.m. She said the HR department informed the facility when a new employee could begin to work. She said she did know that when a person submitted information for a background check, that the facility needed to wait for the information to be returned to allow someone to work on the floor with the residents. She said RN #4 worked Friday night 1/17/23 and into the morning of 1/18/23. She said sometime during RN #4's shift he left a letter under her office door. She said the letter revealed he would not be returning to the facility to work. She said the company did not have a hiring policy but had a procedure of how to hire individuals. The HRD was interviewed on 2/27/23 at 3:28 p.m. He said for employment at the facility a person must get a TB (tuberculosis) test and have it read, a background check through a background company the facility utilized (company name), drug testing and the CAPS (Colorado Adult Protective Service) check. The HRD said on 1/1/23 RN #4 submitted information into the background check company's web site. He said on 1/17/23 the HRD was notified by the background company to have RN #4 resubmit his online background check because his RN license number was not submitted correctly, and RN #4's timeline of where he lived and worked for a few years did not correspond to each other. The HRD said he assumed RN #4 just made a mistake when he entered the information. The HRD spoke with RN #4 over the phone and requested RN #4 sit with the HRD personally to resubmit information and to complete the CAPS form which was part of the background check. The HRD said RN #4 told him he had a backpack that he should not have had that was filled with illegal substances. He said the RN had worked in the facility before as an agency nurse. He said RN #4 had been able to be a contract employee because his felonies were not in the records yet in another state. The HRD said he allowed RN #4 to work on the floor with residents pending his background checks returning. The HRD said the facility allowed him to work before his background checks and CAPS had been returned to the facility. The HRD said the HR department informed RN #4 that because narcotics were involved he did not meet the company standards and could no longer work at the facility. He said the facility suspended RN #4 on 1/27/23 and then fired RN #4 on 1/30/23. He said the last day he worked was 1/27/23. (See variance in account of suspension versus NHA interview stating RN #4 quit.) The HRD said a person could have direct care with residents before a background check was returned even if the person had a criminal background. He said RN #4 would have been supervised in the building when he worked but he did not know who would have supervised him or if he was supervised by anyone if he was the midnight supervisor. The HRD said he told RN #4 he would sit with him on Tuesday 1/24/23 to resubmit his information into the computer system for doing his background check. He said RN #4 agreed but then stated he could enter the computer information with the HRD on 1/26/23 instead. He said on 1/26/23 RN #4 said he needed to speak with his girlfriend about the background information prior to entering it into the computer with the HRD and would sit with the HRD on the following Monday 1/30/23 to reenter his background check into the computer system to verify his background. The HRD said he did not know why RN #4 had to speak to his girlfriend before he filled out the background check. He said the facility did not take him off the schedule until his background check was completed. He said the facility continued to let him work before the background check was resubmitted and returned completed. He said he gave RN #4 permission to work on the floor with residents before the facility received his completed background check. He said when someone did not meet the company standards, such as a felony, or possession of drugs, they were no longer allowed to work for the company. The HRD was interviewed again over the phone on 2/28/23 at 9:54 a.m. He said the facility let RN #4 work with vulnerable residents without a background check. He said, The buck stops here, the HR office for allowing this to happen. He said he was unaware if the HR department was responsible to report this individual to DORA (Department of Regulatory Agencies).

Based on record review and interviews, the facility failed to develop and implement appropriate quality assurance and performance improvement (QAPI) plans of action to correct identified quality deficiencies, potentially affecting all the residents in the facility. Specifically, the quality assurance performance improvement (QAPI) committee failed to effectively address concerns related to: -Healthcare workers following resident's advance directives. On [DATE] a resident did not have his wishes honored which was followed by death; -Provide ongoing interventions and evaluations after the death of a resident who did not have their medical orders for scope of treatment (MOST) form honored, so that other residents would have their MOST form wishes carried out by the facility staff; -Education to the facility staff and facility medical providers to properly implement the MOST form utilized in the facility for advance directives; -Update the facility policy which included the facility had an Automated External Defibrillator (AED) in the building. The facility did not have an AED in the building; and, -Update the policy that anyone trained or not trained could perform cardiopulmonary resuscitation (CPR) to only trained individuals could perform CPR. Findings include: I. Facility policy and procedure The Quality Assurance and Performance Improvement policy, revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 12:35 p.m. revealed in pertinent part, It is the policy of the (facility name) to facilitate quality assessment and performance improvement within a structured process. Each campus will have a committee with key members who will meet quarterly at a minimum to review and analyze data and provide recommendations for performance improvement. The committee identifies opportunities or quality improvement through assessment and data analysis. This may include opportunities in risk and/or hazard identification, quality of life, overall wellness, health/wellbeing, care process, or any other areas which may impact care and wellbeing. Staff is encouraged to identify opportunities for improvement as well as potential hazards and risks. The QAPI committee will recommend and/or implement strategies designed to improve performance and/or correct/minimize risk or hazard. The performance improvement plans will contain measurable outcomes. II. Cross-reference citation F678 During the complaint survey from [DATE] to [DATE], cardio-pulmonary resuscitation was cited at an immediate jeopardy scope and severity. On [DATE] Resident #1 signed his own advance directive on the Colorado MOST form to receive CPR should it be needed. On [DATE] the resident's nurse practitioner signed the MOST form which documented his wishes were discussed with a healthcare professional. On [DATE] his MOST form was reviewed with the social service director (SSD) and the resident's family. It was documented he wished to receive CPR if needed. Later that same day on [DATE], the facility did not honor his wishes and did not perform CPR. Resident #1 passed away and emergency medical personnel were unable to revive him. After the incident, the QAPI committee did not identify and put interventions in place concerning resident's resuscitation choices to prevent the same situation from occurring again. III. Interviews The NHA and the interim director of nursing (IDON) were interviewed on [DATE] at 5:30 p.m. The IDON said, I don't really know, I am not 100% sure if a doctor's decision would trump a resident's MOST form decision. I have not had any specific training on how the MOST forms are to work. I think our nurses understand it, but they have had no specific training on the subject. The NHA said in new employee orientation there was training on the MOST forms. The NHA said she would provide proof of the MOST form training given in new employee orientation. -No documentation was provided of the MOST form training during new employee orientation by exit of the survey [DATE]. The NHA said the facility had a CPR (cardiopulmonary resuscitation) policy. She said I am not clinical so I cannot comment on what the policy says to do. (see facility follow-up) The facility medical director (MD) was interviewed on [DATE] at 9:09 a.m. He said he was in attendance in a QAPI meeting where the situation with Resident #1 was discussed. He said a QAPI meeting was a protected discussion but he hoped the NHA would be asked what happened in the meeting and provide some information. He said he had spoken to the former director of nursing (FDON) in the QAPI meeting about what happened with Resident #1 but that was a protected conversation. He said he would speak to the NHA about providing education to the staff as well as the attending providers concerning CPR and the MOST forms. The NHA was interviewed on [DATE] at 2:58 p.m. She said she was unaware the facility's CPR policy documented the facility had an automatic external defibrillator (AED) that staff were to utilize when needed. She said the facility did not have an AED in the building. She said during the survey, she would update the CPR policy. She said she was unaware the policy documented trained or untrained rescuers could perform CPR. She said the policy was not reviewed during QAPI after the [DATE] passing of a resident. (see facility follow-up below) The NHA was interviewed on [DATE] at 12:10 p.m. She said the QAPI meeting met one time per month. She said she remembered what had happened with Resident #1's death and the death was discussed in a QAPI meeting. She said Resident #1 died on [DATE] and she could not recall if his death was discussed in the [DATE] or [DATE] QAPI meeting. She said she did not have any notes about the subject from the QAPI meeting that she could provide. She said Resident #1's death was a one time discussion only. She said the situation with Resident #1 was never reviewed in any further QAPI meetings and there was no investigation into the situation. She said she did not remember what was discussed in detail about the situation with Resident #1 in the QAPI meeting. She said no interventions were put in place because no interventions were required to be implemented because she felt it was a one time situation. She said a review of all of the residents in the facility MOST forms was not done until the survey on [DATE]. She said the facility's CPR policy was not updated until the survey on [DATE]. She said there were no risk or hazard evaluations identified during the QAPI meeting after Resident #1 died . She said the committee did not discuss what happened with Resident #1 in any meetings until the current survey on [DATE]. She said the QAPI committee discussed in the QAPI meeting that Resident #1 had died and that his family was notified, but that was all. IV. Facility follow-up On [DATE] at 8:30 a.m. during the survey, the NHA and the IDON provided an all resident facility audit to determine each resident's MOST form wishes. The IDON said the audit was incorrect because it did not include one resident who wanted CPR on his MOST form. The NHA and IDON updated and provided a new resident roster of the MOST forms on [DATE] at 8:50 a.m. Updated CPR policy The Emergency Procedure - Cardiopulmonary Resuscitation policy 2001, and revised February 2018, was provided by the NHA on [DATE] at 2:58 p.m. The policy was reviewed with the NHA. The NHA said she was unaware of two parts of the policy which she would revise immediately during the survey. The two parts revealed in pertinent part; Instruct a staff member to retrieve the automatic external defibrillator (AED). -Interviews reveal the facility did not have an AED. The NHA said she did not know the policy stated the facility had an AED for staff to use. All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. -The NHA said she would remove the word not from the policy which indicated CPR could be provided by anyone. She said CPR should only be performed by a trained rescuer. On [DATE] at 4:32 p.m. the NHA emailed a revised CPR policy correcting the above statements. The new policy deleted that there was an AED in the building for staff to use. The new policy revealed all rescuers who provided CPR were to be trained. On [DATE] at 5:40 p.m. the NHA emailed a facility plan which documented the facility would provide in-service CPR education for the licensed facility staff, and all licensed and contract staff would receive written and in-person training on the Colorado MOST forms.

Based on observations, record review and interviews, the facility failed to ensure the medical record was complete and accurate in keeping with accepted standards of practice for one (#1) resident reviewed for documentation out of five sample residents. Specifically, the facility failed to ensure documentation was completed for Resident #1's for his change of condition after staff interviews revealed the former director of nursing (FDON) responded, made observations and assessed the resident. Findings include: I. Facility policy The Charting and Documentation policy, revised February 2023, was provided by the NHA on [DATE] at 11:02 a.m. It read in pertinent part, Entries may only be recorded in the resident's clinical record by licensed personnel in accordance with state law and facility policy. The following information was to be documented in the resident medical record: objective observations, treatments or services performed, changes in the resident's condition and events, incidents or accidents that involved the resident. Documentation should include care-specific details such as: the name and title of the individuals who provided care; the date and time the procedure/treatment was provided; the assessment data or any unusual findings obtained during the procedure or treatment; how the resident tolerated the procedure/treatment; the notification of family, physician or other staff, if indicated; and the signature and title of the individual who documented. II. Resident #1 status Resident #1, over age 65, was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included stroke, right side weakness, speech disorder, heart disease, high blood pressure, neuropathy, osteoporosis, dysphagia (swallowing difficulties), elevated serum lipids and internal cardiac defibrillator placement. The [DATE] minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of eight out of 15. He required two person assistance with bed mobility, transfer, dressing, toileting and personal hygiene. He needed set up assistance only with meals and mobility in the room and corridor did not occur. III. Record review A review of the [DATE] clinical note entered at 7:03 p.m by registered nurse (RN) #1 revealed an unidentified certified nurse aide (CNA) notified RN #1 that Resident #1 was unresponsive when they attempted to serve the meal tray at dinner. RN #1 came in to assess the patient and noted it was difficult to locate a pulse, his breathing was normal, and he appeared pale in color. RN #1 notified the facility physician (FP) who was in the facility. An unidentified staff member called 911. Paramedics attempted resuscitation for approximately 30 minutes without a response. A physician from a local hospital pronounced Resident #1's death at 6:02 p.m. The FP called and notified the family of the resident's passing. -This was the only clinical note entry for Resident #1's change of condition and the facility response. IV. Interviews CNA #3 was interviewed by phone on [DATE] at 2:25 p.m. She said the FP and the former director of nursing (FDON) came in to Resident #1's room on [DATE] in response to being notified about Resident #1's change of condition. CNA #3 said the FP called time of death, and the FP spoke to the paramedics, and the paramedics asked if cardiopulmonary resuscitation (CPR) had been done and the FP said no. CNA #3 said she was not told to do CPR by the FP and did not perform CPR. CNA #3 said the FDON was present in Resident #1's room at this time. The former director of nursing (FDON) was interviewed by phone on [DATE] at 4:27 p.m. The FDON said she went down to Resident #1's room and the FP was there and the FP said she did not want anyone doing CPR because it would not help. The FDON said when she got to Resident #1's room he was cold to the touch and not breathing. She said she observed the FP attempting and unable to feel a pulse and the FDON said the FP checked the apical (near the heart), femoral (near the groin), and there was no pulse, and Resident #1 was barely breathing then he stopped breathing altogether. The FDON said the FP declared a time of death, but the facility did not document when the FP called the time of death. The FDON said said she heard the FP tell CNA #3 to not perform CPR. The FDON said the FP told her told it would not do any good to do CPR. The FDON said from this time until the paramedics arrived, the FP was just sitting there saying she did not want CPR done and that CPR would not do any good. CPR was not performed. The FDON said RN #1 was at the nurses station when paramedics arrived. The FDON stated the paramedics did CPR because Resident #1 was a full code and she said the facility staff should have performed CPR. The FDON emailed additional information on [DATE] at 11:09 p.m. The email read in pertinent part, On [DATE]nd, at 6:18 pm, she informed the administrator through a text message of Resident #1's condition at the time she entered the room, and informed her that the FP refused to do or allow others to perform CPR, and the FP pronounced the time of death but she did not recall the exact time. She told the FP that CPR should have been started. The FP said she was aware that Resident #1 was a full code but didn't want CPR done because she felt it wouldn't have done any good. The FDON did not know how long the resident had been deceased when she (the FDON) entered the room. When the FDON entered the room, the FP was standing at the bedside with an isolation gown on. The resident was blue, cool to touch, no carotid pulse and no respirations were noted. All details were reported immediately to the administrator. The incident was discussed again with the administrator on Monday, [DATE]th. The FDON informed the administrator that this incident needed to be reported. The administrator said she would take care of it and not to discuss it with staff. -The observations and assessments from the FDON interview and email were not documented Resident #1's clinical record. The interim director of nursing (IDON) was interviewed on [DATE] at 9:41 a.m. She said any change of condition note or any kind of assessment should come from the nurse who performed the action. She said she saw the FDON did not write a note regarding Resident #1's change of condition, including her observations and assessments. She said the FDON should have written a note that contained her account of the events, any assessments and what she did from the FDON's point of view. She said she was putting together training documentation for staff that included when and what to document, and how to do that consistently. She said she was unsure whose responsibility it was to ensure a director of nursing entered documentation in a resident's medical record. The nursing home administrator was interviewed on [DATE] at 10:36 a.m. She stated that she did not think the FDON provided patient care and was instead at the nurses station during Resident #1's change of condition. She said if the FDON assessed the resident then there should be documentation she was present. The NHA said the interim director of nursing (IDON) provided a quick training for licensed staff two weeks ago on [DATE] and [DATE] on charting and documentation. V. Facility follow up The NHA provided a training document on charting for the week of [DATE] on [DATE] at 11:02 a.m. It read in pertinent part, Charting necessary documentation should be completed each shift. What should be charted: change in resident condition, incidents, follow up charting (falls, medication changes), provider visits to the resident and any other pertinent information. The training document listed seven nurses who attended the training.

Based on observations, record review and interviews the facility failed to ensure one (#4) of three residents reviewed for range of motion services were provided with services or treatments to prevent a reduction in range of motion out of five sample residents. Specifically, the facility failed to ensure range of motion services were provided for Resident #4. Findings include: I. Resident #4 A. Resident status Resident #4, age 83, was admitted on [DATE]. According to the February 2023 computerized physician orders (CPO), diagnoses included Alzheimer's, dementia, anxiety, depression and malnutrition. The 12/20/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. The resident required two person assistance for bed mobility, transfers, dressing and toileting, and one person assistance for eating, hygiene and locomotion in her room and on the units. II. Observations On 2/23/23 at 11:00 a.m., the resident was sitting in her wheel chair. The resident's legs were extended, however the right lower extremity did not rest directly on the padded foot rest, it remained in an extended position. On 2/27/23 at 11:43 a.m., the resident was sitting in her wheel chair. The resident's legs were extended, however the right lower extremity did not rest directly on the padded foot rest, it remained in an extended position. III. Resident representative interview The resident's representative was interviewed on 2/27/23 at approximately 1:30 p.m. She said the range of motion had not been discussed with her or offered, however, if the range of motion helped with positioning then she would like to see if performed for Resident #4. IV. Record review The 3/27/22 restorative needs evaluation revealed the resident had lower extremities limitations. The current active falls care plan dated 3/29/22, documented the resident was at risk for falls with a goal to have no falls or fall related injury before the next review date. Pertinent interventions included to provide restorative care and activities to enhance posture, the ability to stand safely and walk. -The restorative care intervention failed to include the necessary equipment, frequency, and duration, as well as the measurable objectives and resident goals, what the resident was expected to achieve, such as mobility goals, and/or range of motion measurements to be achieved within a specific timeframe. The intervention failed to determine progress that included whether or not the resident was able to maintain or increase range of motion and/or mobility. -The resident's comprehensive care plan also did not include a mobility care plan or care plan for contractures that addressed the resident's physical limitations or interventions that included exercises and/or therapy to maintain or improve the range of motion and mobility, or to prevent, to the extent possible, declines or further declines in the resident's range of motion or mobility. Clinical notes were reviewed from 9/22/22 to 2/27/23 revealed: The 12/5/22 hospice nursing clinical note revealed the resident was leaning to the right, and the doctor noticed the resident's legs were floating (unable to bend completely) because of stiffness, and documented the resident looked rigid. The hospice notes signed 12/5/22 revealed the resident had rigid extremities, her legs were extended and did not touch the foot rests of her wheelchair. The hospice notes signed 12/28/22 revealed the resident's rigidity was to be monitored for the following two weeks. There were no other hospice notes provided. The 1/3/23 MDS assessment, function limitation in range of motion section, revealed there was nothing marked to indicate a limitation that interfered with daily function for either the upper or lower extremity or that placed Resident #4 at risk of injury. The 1/3/23 MDS therapies section revealed there was no restorative nursing program performed for at least 15 minutes a day for the last seven days. The 1/29/23 clinical note revealed the resident had limited range of motion to her legs with limitation at her hips due to contractures during a post fall assessment. The 2/14/23 clinical note revealed the family stated the resident was not taken to activities and they would like to make sure the resident was included in activities like tactile, music and body movement. The resident was seen on 2/27/23 by the hospice certified nurse aide (CNA). It documented the resident received a shower, oral care and had her hair washed. The charge nurse was informed. The resident was not provided range of motion services by the hospice CNA. IV. Staff interviews The nursing home administrator (NHA) was interviewed on 2/21/23 at 11:00 a.m. The NHA said the facility did not have a restorative program, and she had a performance improvement plan. Registered nurse (RN) #8 was interviewed on 2/27/23 at 1:15 p.m. RN #8 said that the resident did not have any restorative program. She said that she was not sure if the resident received ROM. She said the resident would benefit from ROM as she had impaired mobility in her lower extremities. The IDON was interviewed on 2/27/23 at 2:31 p.m. The IDON reviewed the care plan and confirmed the resident's limited range of motion on her lower extremities was not on the care plan. The NHA was interviewed a second time on 2/27/23 at 4:00 p.m. The NHA said the team, which included the director of nursing (DON), assistant director of nursing (ADON) and the director of rehabilitation (DOR) were meeting bi-weekly in order to develop a restorative program. However, both the DON and the ADON had resigned and no longer worked at the facility. She said the DOR was in charge of writing the policy and provided training to the staff. She said the restorative program needed to be a functional maintenance program. However, the performance improvement plan was at a stand still. Certified nurse aide (CNA) #6 was interviewed on 2/28/23 at approximately 1:00 p.m. The CNA said she did not perform range of motion on any of Resident #4's upper or lower extremities. She said the resident was on hospice care. The director of rehabilitation (DOR) was interviewed on 2/28/23 at 4:30 p.m. The DOR said she was involved with the process, and was writing the policy. She said that due to losing the DON and the ADON, the plan had not progressed. She said the facility had identified there was not a restorative program, however, she was not directly in ensuring residents such as Resident #4 received ROM. V. Facility follow up The facility provided a performance improvement plan. The performance improvement plan had an end goal date of 3/31/23. The first meeting occurred December 2022. The plan included the DOR, DON and ADON. -The plan failed to include how the facility was providing ROM services to the residents, as it was identified they were not receiving any services.

Based on observations, record review and interviews, the facility failed to ensure effective infection control practices were maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections on two of three units. Specifically, the facility failed to ensure all staff were appropriately screened prior to working in the facility. Findings include: I. Professional reference According to the CDC Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, last revised 6/15/2020, retrieved on 9/15/2020 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. If they are ill, have them keep their cloth face covering or facemask on and leave the workplace. II.Facility policy and procedure The Employee Screening Policy, revised 8/28/2020, was provided by the nursing home administrator (NHA) on 9/8/2020 at 12:19 p.m. It read, in pertinent part, If entering any facility, all employees must undergo a health screening process using the designated screening tool. Failure to cooperate with the health screening process or bypassing the process will be subject to disciplinary measures, up to and including termination. Entrance to the facility will be denied if the screening produces a high-risk result. III. Record review Staff screenings were reviewed for five days prior to the 9/8/2020, staff screenings were missing on three days. On 8/31/2020, the facility failed to obtain and document the temperature and screening for certified nurse aide (CNA) #1 and CNA #2. On 9/1/2020, the facility failed to obtain and document the temperature and screening for CNA #1 and CNA #3. On 9/2/2020, the facility failed to obtain and document the temperature and screening for CNA #1. IV. Staff interviews CNA #4 was interviewed on 9/3/2020 at 11:30 a.m. He said he was screened upon entrance to the facility before every shift. He said the nurse working the COVID-19 unit screened him because he only worked on that unit and was unable to enter through the front door. Registered nurse (RN) #1 was interviewed on 9/3/2020 at 11:30 a.m. She said the nurse working the floor on the COVID-19 unit screened her prior to starting her shift. She said it was documented on a paper and left in a notebook on the unit. The NHA was interviewed on 9/3/2020 at 12:54 p.m She said they were unable to find the missing staff screenings from 8/31/2020, 9/1/2020, and 9/2/2020. She said each nurse manager on the unit should verify that all staff screenings were completed, however there was not a process to verify that nurse managers were reviewing staff screenings. The NHA was interviewed again on 9/8/2020 at 11:50 a.m. She said CNA #2 started a split shift on 8/31/20 after the front door screener left for the day. She said staff did not usually enter after the screener left for the day, but she would implement a new process to address when this happens in the future to ensure all staff are screened. The NHA and director of nursing (DON) were interviewed on 9/8/2020 at 12:11 p.m. They said CNA #1 and #3 worked only on their COVID-19 positive unit and were not screened at the main entrance. They said the nurse working should screen all incoming staff members. They said there was not a consistent process of where to put staff screening forms for record and some screenings were lost. V. Facility COVID-19 status The NHA was interviewed on 9/8/2020 at 10:30 a.m. She said they had four COVID-19 positive residents and two COVID-19 positive staff. She said there were zero presumptive positive COVID-19 residents and zero pending COVID-19 tests for staff.

Based on record review, resident representative interview and staff interviews, the facility failed to notify the resident's legal representative of a change in condition for one (#1) of three sample residents. Specifically, the facility failed to notify Resident #1's representative when changes in behaviors occurred, decreased appetite, medication dosage change and when a new pain medication was ordered for Resident #1. Findings include: I. Facility policy and procedure The Acute Condition Changes Clinical protocol policy, revised March 2018, was provided by the interim nursing home administrator (INHA) on 8/13/20 at 2:30 p.m. It read in pertinent parts, direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. The nursing staff will contact the physician based on the urgency of the situation. -The policy did not include legal representative notification. II. Resident status Resident #1, age 77, was admitted on [DATE] and was discharged on [DATE]. According to the May 2020 computerized physician orders [REDACTED]. The 5/7/20 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments. The MDS identified the resident's speech was clear but she was unable to make herself understood. A brief interview for mental status (BIMS), was not completed due to cognitive impairments. The resident required extensive assistance from staff with bed mobility, transfers and limited assistance with eating. III. Record review A. Progress notes The progress note dated 5/5/2020 documented: the resident was very tearful today, the patient had a very poor appetite. The progress note dated 5/6/2020 documented: resident restless and agitated this night until midnight. Resident needed extra reassurance and care to take medication. Resident was verbalied she needed to get out of here and go home to her father sitting on the edge of the bed. Not wanting to lie down. Resident was groaning, and facial grimacing when this writer assisted the resident to sit up. As needed(PRN) Tylenol was administered. The progress note dated 5/7/2020 documented resident is tearful at this time, unable to redirect/reassure resident. Appetite fair, needs to be fed by certified nurse aide(CNA). The progress note dated 5/10/2020 documented: appetite and fluid intake fair with one person assistance with feeding. Resident with an episode of tearing up and crying. Able to redirect at times, CNA in the resident's room throughout the day sitting with the resident and offering reassurance and redirection. The progress note dated 5/10/2020 documented: resident tearful at times. Appetite fair, resident need to be fed by CNA. The progress note dated on 5/12/2020 documented: resident appetite and fluid intake are very poor, supplement offered, resident refused. Resident needed one person's assistance with feeding. Resident groans, moans and holler out. Resident has issues articulating words, the resident does not communicate her needs, the resident slides down in her wheelchair during the day. The facility failed to notify Resident #1 legal representative of changes in condition documented above. B. Physician orders [REDACTED]. The TO dated 5/8/2020 included: Discontinued (D/C) Tylenol current order. Tylenol 500mg tablets, give two tablets by mouth three times a day (TID) and [MEDICATION NAME] (narcotic medication) 25mg every six hours as needed for pain. Resident #1's Tylenol was increased from 2000mg daily to 3000mg daily and a new pain medication [MEDICATION NAME] 25mg was ordered. The facility failed to notify the Resident #1's legal representative when pain medication changes were made and when a new pain medication was ordered for the resident. IV. Resident representative interview On 8/12/2020 at 10:37 a.m., the resident legal representative was interviewed. She said her mother lived at the facility for about two weeks. She said the facility did not notify her and her dad that her mother had a decreased appetite. She said the facility gave her mother pain medication and did not notify them. She said there had been poor communication with facility staff . She said her mother had never taken [MEDICATION NAME], she said the facility ordered [MEDICATION NAME] and administered it to her mother and did not notify them. She said her mother was a thin woman and she believed the pain medication made her lethargic and she believed that was why her mother was not eating. She said the facility staff did not notify them of the changes in her behaviors. She said she was upset because of the poor communication with facility staff. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 8/13/2020 at 10:30 a.m. She said the policy was to notify the resident representative of any change in condition such behaviors, abnormal x-rays and medication changes. She said for behavior changes, the nurse documented in the progress note that the resident representative was notified. She said for medication changes or new medication orders, the nurse notified the resident representative and it was documented on the physician's orders [REDACTED].#1's legal representative was notified of her change in condition when she was in the facility. She said it had been three months since the resident was discharged from the facility. She said if the nurse had notified Resident #1's legal representative, it was documented in the progress note or physician order. Registered nurse (RN) #1 was interviewed on 8/13/2020 at 11:00 a.m. She said she was the nurse supervisor. She said if a resident had a change in condition such as falls, decreased appetite, behaviors or medication changes, the nurse notified the resident's legal representative and documented it in the progress note. She said sometimes they would notify the legal representative verbally when they were at the facility. She said for medication changes and new medications orders, the nurse would notify the resident's legal representative and document it on the physician orders. She said she did not remember Resident #1 because it had been three months since the resident was discharged from the facility. She said if the resident's legal representative was notified, it should be documented in the progress notes or the physician orders.

Based on record review, observation and interview, the facility failed to ensure one (#1) of three sample residents was provided care and services according to the nursing standards of practice and remained free from neglect. The facility failures contributed to delayed healing and/or worsening of the resident's wounds, the development of new wounds, and a neglectful lack of necessary resident care and services. Cross-reference F684, failure to provide the highest practicable quality of care; and F609, failure to timely report neglect to the proper authorities. Findings include: I. Facility policies A. The Abuse policy, dated 7/20/18, was provided by the interim nursing home administrator (INHA) on 6/17/2020 at 4:30 p.m. The policy read, It is the policy of the facility that each resident will be free from Abuse. Abuse can include verbal, mental, sexual, or physical abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. B. The Abuse Prevention Program, dated 7/20/18, was provided by the INHA on 6/17/2020 at 4:30 p.m. The policy read in pertinent part that it was the policy of the facility to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation, involuntary seclusion or misappropriation of resident property. The policy documented, An owner, licensee, Administrator, Licensed Nurse, employee or volunteer of a nursing home shall not physically, mentally or emotionally abuse, mistreat or neglect a resident. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. II. Facility investigation The facility investigation was provided by the IDON on 6/17/2020 at 1:30 p.m. Review of the investigation revealed facility staff first identified Resident #1 had wounds to his left and right heel on 5/23/2020 during interviews 5/27/2020; however, assessment of the wounds to include characteristics of the wounds, causation, notification to physician or family, implementation of interventions and treatment orders were not implemented until four days after the wounds were identified. According to the facility's investigation, started on 5/27/2020, the interviews revealed the resident's nurse was notified on 5/23/2020, by his CNA, that the resident had a blister on his right heel which leaked fluid. The interim director of nursing (IDON) was notified on 5/27/2020 that the resident had wounds to both heels. The resident's heels were assessed on 5/27/2020. The assessment revealed Resident #1 had acquired a DTI to the left heel and a stage II pressure injury to his right heel on 5/27/2020. The failure of the facility nursing staff, on 5/23/2020, to assess Resident #1's heels, document the findings, and failure to notify the physician and family of Resident #1's change of condition (COC), resulted in the resident's heels being unassessed and untreated for [REDACTED]. CNA #4 was interviewed by the IDON on 5/27/2020. In her statement she said she reported to registered nurse supervisor RNS #2 that on 5/23/2020 while putting Resident #1 to bed her and another CNA (unknown) noticed he had a blister to his right heel which was leaking, so they put a brief under it so it would not get the bed wet. She stated she did not notice any other issues on the other foot. RNS #2 was interviewed on 5/27/2020. In her statement she said on 5/23/2020 she received in report from the day nurse that Resident #1 had a blister and adjustments made to his medications. She sated Resident had a blister to his left heel that was small (contradictory to the statement above, and later interviews see below). She said at 12:30 a.m. on 5/24/2020 she was notified by the CNA that while transferring the resident to bed they heard a pop and the resident's blister opened and drained; however, the skin was intact and a dressing was not required (this also was contradictory to the statement above and follow-up interviews below). She said there was no deep tissue injury (DTI) to the resident's heels. She also stated at 1:00 a.m. on 5/24/2020 she reported to the on-coming registered nurse (RN) #3 that the area needed to be observed for any changes or new orders and reported the same information to the on-coming RNS #3 at shift change the following morning. The interviews revealed, Nursing reported during shift report that the resident had bilateral heel blisters present on 5/23/2020 and skin prep was applied to affected areas. The resident's medical record was reviewed and revealed, Nurse's notes and weekly skin assessments did not indicate resident had blisters to his heels and the treatment administration records (TAR) showed no evidence of monitoring to blisters on bilateral heels. Although the facility completed an investigation of wound development to Resident #1's bilateral heels and provided the nursing staff education on abuse prevention and wound prevention, the facility did not follow standards of practice timely, and there was a delay in assessment and treatment. The facility failed to monitor and document wound treatments to the resident's bilateral lower extremities on admission as well as failed to monitor newly found wounds to his bilateral heels for four days, which put the resident at risk for delayed healing and at risk for infection. The facility determined the investigation of neglect was unsubstantiated. III. Failure to keep Resident #1 free from neglect. A. Resident status Resident #1, age 87, was admitted on [DATE]. According to the June 2020 computerized physician orders [REDACTED]. The 4/19/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. He exhibited verbal and physical behaviors towards others and at times would resist care. He required extensive two-person assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. He was frequently incontinent of the bowel and bladder. The resident had one or more unhealed pressure ulcers. The number of stage 2 pressure ulcers present was documented as two. The number of these stage 2 pressure ulcers that were present upon admission/entry or reentry was documented as two. The number of venous and arterial ulcers present was documented as two. The resident had a pressure reducing device for chair, pressure ulcer/injury care, application of nonsurgical dressings and application of ointments/medications. The documentation was blank for the turning and repositioning program and pressure reducing device for bed. B. Observation and staff interview On 6/17/2020 at 11:55 a.m., IDON, licensed practical nurse (LPN) #2 unknown certified nurse aide (CNA) #3 were observed providing wound care to Resident #1's BLE and bilateral heels. Resident #1 was observed in bed. He had bilateral Prevalon boots on his feet and his heels were floated with pillows. CNA #3 repositioned Resident #1 and removed his Prevalon boots and was asked to help hold the resident's legs during wound care. The IDON said Resident #1 was admitted with multiple scabs to his bilateral lower extremities and then developed pressure ulcers to his heels. The IDON removed the dressing to Resident #1's right heel. The wound had sanguineous (fresh bleeding) drainage, no signs or symptoms of infection, the surrounding tissue was macerated. The IDON said the wound was a stage 2 which had worsened. She said the reason it worsened was because the resident had [MEDICAL CONDITION] and poor blood flow. The wound bed (mid wound) had 50% necrotic eschar, and 50% pink pale skin surrounding the eschar. It measured 6.0 x 5.0 cm. The right great toe was an intact scabbed area with 100% eschar, it measured 1.5 x 1.5 cm. There was slight redness to surrounding skin. The IDON said Resident #1 was on the last day of antibiotic treatment for [REDACTED]. The right inner ankle (malleolus) was intact, red and non- blanching. It measured 1.5 x 1.6 cm. The IDON said there was a scab that lifted to the area. The pressure ulcer to the left heel had a black cap, 100% eschar and its wound edges were attached to the wound bed, there was no drainage. It measured 3.3 by 5.3 cm. The IDON said the wound initially was a deep tissue injury but now was unstageable. The IDON said she would have the staff contact the physician for new treatment orders to the right heel, and planned to continue alcohol prep to the left heel. They continued to measure and treat all other scattered scabs to Resident #1's bilateral lower extremities per physician orders. C. Record review 1. Care Plans The resident's comprehensive care plan, dated 4/20/2020, documented the resident was admitted with multiple scabs and bruising to his bilateral lower extremities (BLE). He was at risk for skin breakdown related to incontinence, impaired mobility and presence of comorbid conditions. Staff were to perform complete assessment of skin and areas of redness,, no massage over pressure areas, heelbow protectors. Nursing staff were to check the resident's skin for areas of redness, report any changes to the nurse and perform a complete assessment of skin with areas of redness noted. The care plan was revised on 5/28/2020 following the facility's investigation wound development and treatment. The care plan revealed Resident #1 had facility-acquired wounds to his bilateral heels, SDTI (suspected deep tissue injury) to his left heel and a stage 2 pressure ulcer to his right heel. 2. Assessments a. Review of May 2020 weekly skin assessments documented on the TAR revealed nursing staff documented Resident #1's skin was intact on 5/6/2020 and 5/20/2020. The 5/6/2020 skin assessment did not have additional documentation. The 5/20/2020 skin assessment revealed Resident #1 had scabbed areas to his BUE and BLE, skin prep was applied per physician order. b. The 5/27/2020 wound assessment to the right heel revealed Resident #1 had an open blister, the base color was red with discoloration surrounding the wound, there was a moderate amount of sero-sanguineous (thin, watery, pale red to pink plasma with red blood cells) drainage, and tissue type was granulation tissue. It measured 4.5 x 7.0 x 0 cm. Podus (float) boots and air mattress were ordered. The 5/27/2020 wound assessment to the left heel revealed Resident #1 had a pressure ulcer with necrotic tissue. It was documented as not applicable under the stage. The base color was black, the wound was dry, and the tissue type was necrotic tissue. It measured 6.0 x 4.5 x 0 cm. Podus (float) boots and air mattress were ordered. 3. Physician treatment orders administration The physician treatment from April 2020 and May 2020 revealed nursing staff were to provide the ordered treatments and complete skin assessment monitoring every shift and full body skin assessments were to be done weekly. Treatment orders were provided by the physician on 4/12, 4/14, and 5/27/2020. 4. Treatment administration records (TARs) TAR review revealed Resident #1 refused treatment to his BLE five times in April 2020 and refused treatment to his BLE one time in May 2020. Review of the May 2020 TAR revealed eight different nurses documented they provided the treatment (skin prep) to Resident #1's BLE scabs, abrasions and open areas from 5/23/2020 to 5/27/2020. According to the physician on 6/19/2020 at 8:47 a.m., If the treatment was completed to all scabbed areas including the toes it would be difficult not to assess Resident #1's bilateral heels (see interview below). 5. Progress notes A nurse's note dated 5/23/2020 documented All scabs to BLE skin prepped as ordered. No s/s of infection noted. A nurse's note for 5/28/2020 revealed the treatment to BLE was completed; skin prep applied to scabbed areas. Pressure area with necrotic tissue found on L heel. Two open blisters to the side of L foot. Open blister with discoloration surrounding found on R heel. Head to toe Skin check done findings and measurement with weekly skin assessment. Areas cleaned and dressed. The physician progress notes [REDACTED].#1's wounds. The physician progress notes [REDACTED]. The physician wrote Nurses noticed heel blisters in the past couple of days which have now opened to heel ulcers, unstageable, left heel has large area of eschar and right heel has a large open area, pt. (patient) tends to dig his heels into the mattress when he is laying down, other risk factors include severe dementia and malnutrition. The resident also has unspecified open wound to the right lower leg sequela (resulting from disease injury). IV. Staff interviews LPN #1 was interviewed on 6/16/2020 at 10:20 a.m. The LPN said she was not aware Resident #1 had pressure wounds to his bilateral lower extremities until she was notified by LPN #2 on 5/27/2020. She said the nurses who knew about the wounds before 5/27/2020 should have completed a risk watch and she was notified it was not completed when the wounds were first identified. She said when they assessed Resident #1's wounds on 5/27/2020 the resident had a pressure ulcer to the left heel which was necrotic and the right heel had an open blister with discoloration. She said if the nurse did not complete an assessment of a resident's new wound and notify the physician that would be a form of neglect. CNAs #1 and #2 were interviewed on 6/16/2020 at 4:00 p.m. They said if a resident had a new wound or skin issue they would notify the nurse immediately. RN #3 was interviewed on 6/17/2020 at 3:05 p.m. RN #3 said failing to provide care and services to the resident would be considered a form of neglect. She acknowledged failing to notify the physician and family, assessing a wound or obtaining treatment orders for a new wound would be an example of neglect. She said I'm guilty and failed in that area, I should have notified the Doctor. RNS #3 was interviewed 6/17/2020 at 4:41 p.m. She said the last time she had abuse training was two weekends ago. She said her definition of neglect was not providing resident care needs. She said if a nurse knew about a new wound and failed to treat it that would be considered neglect. V. Administrative interviews The IDON was interviewed on 6/16/2020 at 12:55 p.m. She said she started interviewing the nurses about Resident #1's wound to his BLE and still was in the process of providing 1:1 education to all nurses about wound care. She stated she could not determine who the specific staff was or the exact date the bilateral heel blisters occurred could not be determined. IDON was interviewed a second time on 6/16/2020 at 4:12 p.m. She said at times the facility would use SBAR (situation, background, assessment, and recommendation) for any change of condition. She said they were not documenting or using SBAR consistently. The DON would ultimately follow-up with the nurses to ensure that they were completed for any change in condition. She said she felt that was a standard at all facilities; however, the nurses there just did not have the skill set of knowing the standards of practice. The IDON was interviewed again on 6/17/2020 at 1:45 p.m. She said she was unaware RN #3 came in to relieve RNS #2 from the floor on the morning of 5/24/2020 so she did not get a statement from RN #3 about Resident #1 having a blister to his heel. She said she attempted to call RN #3 to follow up with her; however, she had not returned her call. The INHA and IDON were interviewed on 6/17/2020 at 6:35 p.m. The INHA stated she was not a clinical person but from her understanding the nurses should have reported and documented the new wounds. The INHA said the nurse who identified Resident #1 as having new wounds should have started an investigation. They agreed that was a standard of practice. The IDON stated the neglect allegation was reported late to the state agency. She said she made that mistake and it would never happen again. The INHA and IDON acknowledged the facility's failures constituted neglect. The physician was interviewed on 6/19/2020 at 8:47 a.m. The physician stated it would be hard to argue that the nurse who saw Resident #1's feet every day would have not seen blisters to his bilateral heels. He said he had no explanation for why the wounds to his bilateral heels would not have been seen when the nurse provided treatment. VI. Facility follow-up In-service training and education was provided by the IDON on 6/17/2020 at 1:30 p.m. The training included abuse training to include neglect and appropriate reporting of abuse (25 staff signed acknowledgment), pressure ulcer training to include assessments, weekly skin assessments, implementation of an intervention, notification to physician and family, obtaining appropriate treatment orders and use of stop and watch assessment/tool. They completed a full house skin audit started on 5/27/2020 and completed on 5/29/2020, no new wounds were identified. The IDON also provided documentation of 1:1 education to front line staff which included when the nurse identified any wound or skin condition they should document their assessment to include, what type of wound or skin condition that is present, what it looks like, if it had infection, what type of drainage it had, if it worsened, notification, documentation and follow-up charting after a skin concern was identified. The INHA provided online facility training of all licensed nurses who had complete wound care risk assessment and care plan training completed by 20 licensed nurses in 2019.

Based on observation, interviews and record review, the facility failed to provide the highest practicable quality of care for one (#1) of three sample residents. Resident #1, who was severely cognitively impaired, had physical and verbal behaviors, was debilitated from a fall and had multiple comorbidities including cerebral infarction (stroke), metabolic [MEDICAL CONDITION], dementia, protein calorie malnutrition, [MEDICAL CONDITION] infarction, and rhabdomyolysis, and was identified as high risk for wound development. He was admitted to the facility on [DATE]. His admission data assessment revealed he had multiple scabbed areas, wounds and abrasions to his bilateral upper extremities and bilateral lower extremities (BLE). Significant wounds were documented to his BLE. The left lower extremity (LLE) wounds included a 20 x (by) 6.4 cm (centimeter) abrasion and a mid shin 13.5 x 2.5 cm abrasion. The right lower extremity (RLE) included a 10 x 5.7 cm lateral to knee/shin abrasion with various scabs, right mid shin 8.7 x 1.5 cm abrasion. The great toe had 2.0 x 2.0 cm abrasion with a 0.8 x 0.5 cm area of slough and the medial malleolus had a 1.5 x 0.5 cm wound with slough. Resident #1 had pressure injuries which were not monitored to his right dorsal (facing upward while standing) great toe and right medial malleolus which were identified on admission (see above and physician note 4/14/2020). In addition Resident #1 developed a wound to his right heel on 5/23/2020 and a wound to his left heel (date unknown). These wounds were identified by nursing staff (see investigation below); however, administration was not notified until 5/27/2020. During the four days the nursing staff did not assess the wounds for causation, document characteristics of the wound, monitor, notify the physician or family, implement interventions, nor obtain physician orders to treat the resident's bilateral heel wounds until they were brought to the interim director of nursing's (IDON's) attention on 5/27/2020. Although the facility completed an investigation of wound development to Resident #1's bilateral heels and provided staff education on standards of practice including notification to the physician/family, treatments, assessing characteristics and monitoring wounds; the facility did not follow standards of practice timely and there was a delay in assessment and treatment. The facility knowingly failed to monitor and document the healing of the open wounds to the resident's bilateral lower extremities on admission as well as failed to monitor newly found wounds to his bilateral heels for four days which put the resident at risk for delayed healing and at risk of infection. On assessment 5/27/2020 Resident #1's left heel was not staged (see wound assessment) and had necrotic tissue (see staff interview); Resident #1's right heel was documented as a stage 2 blister with a red wound base which later was observed to have 50% necrotic tissue (see wound observation below). The facility failures contributed to delayed healing and/or worsening of the resident's wounds, and the development of new wounds. Cross-reference F600, failure to keep the resident free from neglect. Findings include: I. Facility policy The Wound Care policy, undated, was provided by the interim nursing home administrator (INHA) on 6/17/2020 at 4:30 p.m. It documented in pertinent part, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. -The following should be recorded in the resident's medical record: -The type of wound care given. -The date and time the wound care was given. -The position in which the resident was placed. -The name and title of the individual performing the wound care. -Any change in the resident's condition. -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. -How the resident tolerated the procedure. -Any problems or complaints made by the resident related to the procedure. -If the resident refused the treatment and the reason(s) why. -The signature and title of the person recording the data. -Notify the supervisor if the resident refuses the wound care. -Report other information in accordance with facility policy and professional standards of practice. II. Resident #1's status Resident #1, age 87, was admitted on [DATE]. According to the June 2020 computerized physician orders (CPO), [DIAGNOSES REDACTED]. Pressure ulcers were not documented on the June 2020 CPO. The 4/19/2020 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of two out of 15. He exhibited verbal and physical behaviors towards others and at times would resist care. He required extensive two-person assistance with bed mobility, transfers, toilet use and personal hygiene. The resident had one or more unhealed pressure ulcers. The number of stage 2 pressure ulcers present was documented as two. The number of these stage 2 pressure ulcers that were present upon admission/entry or reentry was documented as two. The number of venous and arterial ulcers present was documented as two. The resident had a pressure reducing device for his chair, pressure ulcer/injury care, application of nonsurgical dressings and application of ointments/medications. The documentation was blank for a turning and repositioning program and a pressure reducing device for bed. The resident received antipsychotics for seven out of seven days and antianxiety medication for two out of seven days, and antipsychotics were received on a routine basis only. III. Failure to assess wounds appropriately on admission and failure to assess the development of new wounds. A. Observation and interviews On 6/17/2020 at 11:55 a.m., the IDON, licensed practical nurse (LPN) #2 and certified nurse aide (CNA) #3 were observed providing wound care to Resident #1's BLE to include bilateral heels. Resident #1 was observed in bed. He had bilateral Prevalon boots on his feet and his heels were floated with pillows. A bedside table was observed with a clean field and treatment supplies. All three staff washed their hands and CNA #3 and the IDON donned gloves. LPN #2 was the scribe and CNA #3 repositioned Resident #1 and removed his Prevalon boots and was asked to help hold the resident's legs during wound care. The IDON said Resident #1 was admitted with multiple scabs to his bilateral lower extremities and then developed pressure ulcers to his heels. LPN #2 said treatment orders to the right heel was to clean the right heel with normal saline (NS), apply xeroform to the wound base (the healthy tissue) and not the area with eschar, and wrap with kerlix. The IDON removed the dressing to Resident #1's right heel. The wound had sanguineous (fresh bleeding) drainage, no signs/symptoms (s/s) of infection, the surrounding tissue was macerated. The IDON said the wound was a stage 2 which had worsened. She said the reason it worsened was because the resident had [MEDICAL CONDITION] and poor blood flow which was diagnosed with [REDACTED]. The wound bed (mid wound) had 50% necrotic eschar, and 50% pink pale skin surrounding the eschar. It measured 6.0 x 5.0 cm. The right great toe was an intact scabbed area with 100% eschar, it measured 1.5 x 1.5 cm. There was slight redness to the surrounding skin. The IDON said Resident #1 was on the last day of antibiotic treatment for [REDACTED]. The right inner ankle (malleolus) was intact, red and non blanching. It measured 1.5 x 1.6 cm. The IDON said there was a scab that lifted to the area. The pressure ulcer to the left heel had a black cap, 100% eschar and its wound edges were attached to the wound bed; there was no drainage. It measured 3.3 by 5.3 cm. The IDON said the wound initially was a deep tissue injury but now was unstageable. LPN #2 said the treatment for [REDACTED]. The IDON said she would have the staff contact the physician for new treatment orders to the right heel, and planned to continue alcohol prep to the left heel. They continued to measure and treat all other scattered scabs to Resident #1's bilateral lower extremities per physician orders. B. Record review 1. Care plans The 4/12/2020 individual resident care plan (developed within 48 hours of admission), documented Resident #1 had wounds and documentation was left blank under wound locations. Interventions included repositioning every two hours and barrier cream. Documentation was left blank: under special mattress, heel protectors/elevate heels and wheelchair cushion. The 4/20/2020 care plan report, revised 5/28/2020, revealed Resident #1 acquired wounds to his bilateral heels, SDTI (suspected deep tissue injury) to his left heel, and a stage 2 pressure ulcer to his right heel. Interventions implemented were a physical therapy (PT) evaluation, Doppler venous/arterial with ankle brachial index ABI, Prevalon boot to bilateral feet at all times, assess and record characteristics of the wound, and alternating air mattress. In addition on the care plan Resident #1 rubbed and dug his heels into the bed and would often remove his dressings. -There was no intervention listed for this behavior or no implementation of offloading devices utilized, preventative measures or alternate treatments until the wounds were discovered on 5/23/2020 and not documented (see interviews below). 2. Admission Data Collection and Documentation form The 4/12/2020 Admission Data Collection and Documentation revealed Resident #1 was admitted with multiple scabs and abrasions to his bilateral upper extremities (BUE) and BLE. Although there were orders to apply skin prep to the scabbed areas, there was no documentation to include monitoring healing of larger abrasions, the pressure points as identified by the physician (see below) or the open areas listed on the Admission Data Collection and Documentation form. Also documented on this form was a Braden Scale for predicting pressure ulcers. It revealed Resident #1 was at high risk for developing pressure ulcers with a score of 11 out of 18 (a score of 15-18=At risk, 13-14=Moderate risk, 10-12=High risk, and 6-9=Very high risk). Resident #1's substantial wounds documented to his BLE were as follows: -LLE 20 x 6.4 cm abrasion and mid shin with 13.5 x 2.5 cm abrasion. -RLE 10 x 5.7 cm lateral to knee/shin abrasion with various scabs, right mid shin 8.7 x 1.5 cm abrasion, great toe had 2.0 x 2.0 cm abrasion with a 0.8 x 0.5 cm area of slough and at medial malleolus had 1.5 x 0.5 cm wound with slough. 3. Treatment orders The April 2020 treatment administration record (TAR) revealed Resident #1 had orders as follows: -Starting 4/14/2020 apply skin prep to all scabs and abrasions to BUE and BLE every shift. -Starting 4/14/2020 cleanse all open venous ulcers with normal saline (NS), pat dry, cover with xeroform ([MEDICATION NAME]) gauze and cover with non-adherent [MEDICATION NAME] dressing secure with kerlix. -Starting 4/14/2020 monitor all abrasions and scabs for signs and symptoms of infection every shift. The May 2020 TAR revealed Resident #1 had orders as follows: -Starting 4/14/2020 apply skin prep to all scabs and abrasions to BUE and BLE every shift. -Starting 4/14/2020 monitor all abrasions and scabs for signs and symptoms of infection every shift. -Starting 4/29/2020 cleanse all open venous ulcers with NS, pat dry, apply skin prep, and monitor for signs and symptoms of infection every shift. -Starting 5/27/2020 ensure soft boot is in place to the left foot while in bed. Document in nursing notes any noncompliance every shift. -Starting 5/27/2020 ensure heels are floated while in bed, document in nursing notes any noncompliance. -Starting 5/27/2020 left heel DTI, apply [MEDICATION NAME] to discolored areas, let dry and leave open to air. Monitor for signs and symptoms of infection every shift and document changes in nursing notes. -Starting 5/27/2020 right heel open blister, cleanse with NS, pat dry, apply xeroform gauze to open area, cover with adhesive foam dressing and change daily. Monitor for signs and symptoms of infection and document changes in the nursing notes. According to the April and May 2020 TARs, Resident #1 refused treatment to his BLE five times in April 2020 and refused treatment to his BLE one time in May 2020, on night shift on 5/22/2020. Review of the May 2020 TAR revealed eight different nurses documented they provided the treatment (skin prep) to Resident #1's BLE scabs, abrasions and open areas from 5/23/2020 to 5/27/2020. Interview with the physician revealed if the treatment was completed to all scabbed areas including the toes it would be difficult not to assess Resident #1's bilateral heels (see below). 4. Nursing notes Review of nursing notes from 5/23/2020 to 5/27/2020 revealed one nurse documented completing treatment to Resident #1's BLE. This was documented on 5/23/2020 at 3:05 p.m. There were no other nursing notes documenting he had skin prep applied to his BLE. 5. physician progress notes [REDACTED].>The physician progress notes [REDACTED].#1 had multiple wounds to his BLE. Some were on pressure points such as the right medial malleolus and first metatarsophalangeal (right great toe). It further documented some of the wounds had punched out areas suggestive of arterial ulcers. The physician progress notes [REDACTED].#1's wound to the right medial malleolar region was still large with surrounding [DIAGNOSES REDACTED] (redness). The right great toe and right second toe wounds were closing over well. The physician progress notes [REDACTED].#1's wound to his right medial malleolus had slough and the resident would not keep his dressings on. The physician progress notes [REDACTED].#1's wound to his right medial malleolus was the largest wound, which was becoming more shallow and was covered with a scab. The physician progress notes [REDACTED].#1's wounds. The physician progress notes [REDACTED].#1 had bilateral heel ulcers for the past couple of days. The physician progress notes [REDACTED].#1's pressure ulcers to his bilateral heels were unavoidable due to his abnormal ABI and vascular compromise and the resident was being treated with antibiotics for [MEDICAL CONDITION] to his right great and right second toes. 6. Skin assessments Review of May 2020 skin assessments documented on the TAR revealed nursing staff documented Resident #1's skin was intact on 5/6/2020 and 5/20/2020. The 5/6/2020 skin assessment did not have additional documentation. The 5/20/2020 skin assessment revealed Resident #1 had scabbed areas to his BUE and BLE, and skin prep was applied per physician order. The 5/13/2020 skin assessment documented Resident #1 refused to have his skin assessment completed, however treatment (skin prep) was applied to the resident's BLE per nursing notes and TAR. The 5/27/2020 skin assessment documented bilateral pressure ulcers (see wound assessment below). 7. Facility investigation of Resident #1's bilateral heel wounds The facility investigation was provided by the IDON on 6/17/2020 at 1:30 p.m. Review of the investigation revealed facility staff first identified Resident #1 had wounds to his left and right heels on 5/23/2020 during interviews on 5/27/2020. However, assessment of the wounds to include characteristics of the wounds, causation, notification to physician or family, implementation of interventions and treatment orders, were not implemented until four days after the wounds were identified. CNA #4 was interviewed on 5/27/2020. In her statement she said she reported to registered nurse supervisor (RNS) #2 that on 5/23/2020 while putting Resident #1 to bed, she and another CNA (unknown) noticed he had a blister to his right heel which was leaking, so they put a brief under it so it would not get the bed wet. She stated she did not notice any other issues on the other foot. RNS #2 was interviewed on 5/27/2020. In her statement she said on 5/23/2020 she received in report from the day nurse that Resident #1 had a blister and adjustments were made to his medications. She stated the resident had a blister to his left heel that was small (contradictory to the statement above, and later interviews below). She said at 12:30 a.m. on 5/24/2020 she was notified by the CNA that while transferring the resident to bed they heard a pop and the resident's blister opened and drained. However, the skin was intact and a dressing was not required (this also was contradictory to the statement above and follow-up interviews below). She said there was no deep tissue injury (DTI) to the resident's heels. She also stated at 1:00 a.m. on 5/24/2020 she reported to the on-coming registered nurse (RN) #3 that the area needed to be observed for any changes or new orders and reported the same information to the on-coming RNS #3 at shift change the following morning. The 5/27/2020 wound assessment to the right heel revealed Resident #1 had an open blister, the base color was red with discoloration surrounding the wound, there was a moderate amount of sero-sanguineous (thin, watery, pale red to pink plasma with red blood cells) drainage, and tissue type was granulation tissue. It measured 4.5 x 7.0 x 0 cm. Podus (float) boots and air mattress were ordered. The 5/27/2020 wound assessment to the left heel revealed Resident #1 had a pressure ulcer with necrotic tissue. It was documented as not applicable under the stage. The base color was black, the wound was dry, and the tissue type was necrotic tissue. It measured 6.0 x 4.5 x 0 cm. Podus (float) boots and air mattress were ordered. See below for follow-up to the identification of the facility acquired pressure ulcers. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 6/16/2020 at 10:20 a.m. She said she had worked at the facility for four years and always worked on the skilled unit, which was the 600 hallway. She said none of her residents had any wounds on her unit. She said she did not believe she received any wound care training other than wound vac (negative pressure, vacuum assisted healing) training which she received one year ago by the MDS coordinator. She said they would monitor all wounds such as pressure wounds, surgical wounds and diabetic wounds. She said if a resident developed wounds they would complete a risk watch (internal change in condition form), which included an assessment of the wound, interventions and notification to the physician for treatment orders. RNS #1 was interviewed on 6/16/2020 at 10:30 a.m. She said she had worked at the facility for [AGE] years. She said the MDS coordinator had completed wound rounds. She said she had not received any training related to wound care in the past year. She said she did not remember the last time a resident had a wound in the facility and it had been a long time since a resident had a pressure wound at the facility. She said Resident #1's wounds were likely venous or arterial wounds in nature because Resident #1 had ultrasound and ABI studies completed which showed he had poor blood flow to his bilateral lower extremities. She said if a resident had a new wound that was identified, the nursing staff would complete a risk watch which included measurements, notification, when it was found, the description of the wound, and she would get treatment orders for the wound. She said she was not aware Resident #1 had pressure wounds to his bilateral lower extremities until she was notified by LPN #2 on 5/27/2020. She said the nurses who knew about the wounds before 5/27/2020 should have completed a risk watch and she was notified it was not completed when the wounds were first identified. She said when they assessed Resident #1's wounds on 5/27/2020 the resident had a pressure ulcer to the left heel which was necrotic and the right heel had an open blister with discoloration. She said if the nurse did not complete an assessment of a resident's new wound and notify the physician that would be a form of neglect. RN #1 was interviewed on 6/16/2020 at 11:30 a.m. She said she had worked at the facility for [AGE] years. She said there were no residents with wounds on her unit which was the 500 hallway. She said she had received wound care training through the facility's online training about six months ago. She said she was taking care of Resident #1 on 5/23/2020, the day in which two night nurses reported he had wounds to his heels. She said she worked the day shift that day and she checked Resident #1's skin and he did not have any wounds on his bilateral heels. She said she did not pass along in report the resident had wounds, and if he did she would have followed up as a standard of practice, and would have completed a risk watch form. RN #2 was interviewed on 6/16/2020 at 3:10 p.m. She said she was working on the 400 hallway and there were no residents who had wounds on her unit. She said Resident #1 had wounds but they were not pressure ulcers that required monitoring and were considered venous/arterial wounds in nature. She said if a resident developed wounds they would complete a risk watch assessment. She said she did not know who completed wound rounds. CNAs #1 and #2 were interviewed on 6/16/2020 at 4:00 p.m. They said they regularly worked with Resident #1. They said, When he first admitted he was very violent, he was combative, he kicked, pinched, scratched and spit on us. They said he would fall a lot, he was restless and hard to keep calm and was up and down and would try to stand up alone. CNA #1 said he sun-downed (state of confusion starting late afternoon and spanning into the night). She said he needed one to two-person assistance with all his cares. She said he used to be able to walk before he developed wounds, then he used a mechanical lift for a short while and since he received specialty shoes, and now he was able to bear weight and transfer. They said he wore Prevalon boots while in bed; however, he would remove them. They said they used to float his heels with pillows before the Prevalon boots were added, but he would remove the pillows. They said he had one-to-one care for about five weeks because of his behaviors and multiple falls. They said recently in the past few weeks his behaviors had improved and he was less combative, calm and cooperative. They said while the resident was on quarantine the resident had bed baths, but when he was off quarantine he would take a shower and never refused. They said if a resident had a new wound or skin issue they would notify the nurse immediately. RNS #2 was interviewed on 6/17/2020 at 1:24 p.m. She said on 5/23/2020 she received in report from the day nurse (she was not sure who the nurse was) that Resident #1 had a dime size blister to his left heel and the treatment was skin prep. She said around 12:30 a.m. or 12:45 a.m. on 5/24/2020 the CNAs (CNA #4 was the primary CNA working who notified her and she was not sure who was the other CNA working was) notified her they heard a pop when they put Resident #1 to bed and his blister had ruptured. She said, I initially looked at it and it was a ruptured intact blister and within 10 minutes I gave (RN #3) report and at that time I delegated the observation to her. She said RN #3 did not say she would follow-up, but she said okay. She said she did not follow-up with RN #3 later in the shift to ensure she assessed the resident's heel, but she reported it to on-coming RNS #3 to follow-up. She said she did not return to work at the facility until 5/27/2020 and that was the first day she was aware of the wound to Resident #1's right heel which was a DTI. RN #3 was interviewed on 6/17/2020 at 3:05 p.m. She said she had worked at the facility PRN (as needed) for three years. She said she usually worked two days per week. She said on 5/24/2020 RNS #2 reported to her that the resident had a blister to his left heel. She said she did not know how long it had been there or if it was brand new. She said CNA #4 told her that she told RNS #2 about the ruptured blister. She said she checked the area to Resident #1's left heel and she applied the skin prep to it. She said the left heel blister was intact, deflated and not leaking. She said she told RNS #3 the following day, along with the on-coming nurse about the intact blister. She said she did not notify the physician to obtain treatment orders and she assumed RNS #3 would contact the physician to obtain orders. She said she assumed RNS #3 would implement an intervention. She said she received wound care training when she first started working through an online computer training at the facility. She said she had received abuse/neglect training in the last six months. She said failing to provide care and services to a resident would be considered a form of neglect. She acknowledged failing to notify the physician and family, assess a wound or obtain treatment orders for a new wound would be an example of neglect. She said I'm guilty and failed in that area, I should have notified the doctor. CNA #4 was interviewed on 6/17/2020 at 4:07 p.m. She said she worked full time on the night shift. She said she had taken care of Resident #1 frequently. She said on 5/23/2020 she and another CNA were getting Resident #1 to bed around 8:00 p.m., and they noticed the sheets were wet at the end of the bed, so she removed the resident's right sock which was wet and she noticed the resident had a blister that popped. She said she notified RNS #2 right after and RNS #2 told her she knew the resident had a blister on his heel. She said she asked DNS #2 if she would go and take a look at it because it had popped. She said RNS #2 just told her to put a pillow under it, so she did and also placed a chuck underneath it. She said Resident #1 had non-skid socks on when they put him to bed. She said, I removed his sock to the right foot only and did not think to check his other foot. She said she did not know for sure if RN #3 ever went in to check the resident's heel because she had to finish caring for other residents, and she could not remember the CNA's name who was helping her that night. She said RN #3 came in to work around 12:00 a.m. or 1:00 a.m. to work on that particular unit, but she could not remember if she told her about Resident #1's blister. RNS #3 was interviewed 6/17/2020 at 4:41 p.m. She said she was an RN supervisor that worked Friday, Saturday, and Sunday. She said she worked on 5/24/2020 and did not remember receiving report from RNS #2 that Resident #1 had a blister to his right or left heel. She said she did not remember RN #3 telling her Resident #1 had a blister to his right or left heel. She said, Obviously, if they said they told me about it, then maybe they did but I just don't remember. She said if a resident had a newly acquired wound she would notify the director of nursing (DON). She said she would assess the wound, contact the physician for treatment orders, notify the family, and obtain measurements once a week to ensure the wound was healing. She said they would make sure to check the wound daily. She said the nurses on the floor would complete wound rounds and the physician would monitor via their telehealth visit, and the nurse practitioner (NP) or physician assistant (PA) would follow-up if the wound was getting worse. She said the MDS coordinator would give them information on wounds because she was wound care certified. She said the last time she had abuse/neglect training was two weekends ago. She said her definition of neglect was not providing resident care needs. She said if a nurse knew about a new wound and failed to treat it, that would be considered neglect. V. Administrative interviews The IDON was interviewed on 6/16/2020 at 12:55 p.m. She said she started working at the facility as interim DON on 5/26/2020. She said Resident #1's wounds were found one day after she started on 5/27/2020. She said she was notified by the staff and asked to look at Resident #1's heels. She said he had a DTI to the left heel, and a stage II to the right heel. She said she interviewed staff, they ordered Prevalon boots, an upgraded low air loss mattress, completed a nutritional assessment, and had physical therapy complete an assessment. She said the NP, PA, and physician assessed residents at the facility two to three times a week. She said the facility supervisors would assess the resident's wounds with visits via telehealth (via supervisor phone) and the physician. She said venous studies were completed for Resident #1, which were negative for [MEDICAL CONDITION] or blood clot, and the ABI results were pending. She said she started interviewing the nurses about Resident #1's wound to his BLE and still was in the process of providing one-to-one education to all nurses about wound care. She said weekly skin assessments were being completed; however, the follow-up to any skin conditions such as bruising and scabs were not implemented. Since then, they completed 100% skin audits, and had been completing random skin assessments. The IDON was interviewed a second time on 6/16/2020 at 4:12 p.m. She said at times the facility would use SBAR (situation, background, assessment, and recommendation) for any change of condition. She said they were not documenting or using SBAR consistently. She said the DON would ultimately follow-up with the nurses to ensure that they were completed for any change in condition. She said she felt that was a standard at all facilities; however, the nurses there just did not have the skill set of knowing the standards of practice. The IDON was interviewed again on 6/17/2020 at 1:45 p.m. She said she was unaware RN #3 came in to relieve RNS #2 from the floor on the morning of 5/24/2020 so she did not get a statement from RN #3 about Resident #1 having a blister to his heel. She said she attempted to call RN #3 to follow up with her; however, she had not returned her call. The INHA and IDON were interviewed on 6/17/2020 at 6:35 p.m. The IDON said she was not sure why it was documented on the MDS that Resident #1 had two pressure ulcers and two venous/arterial ulcers upon admission and they were not monitored. She said the MDS coordinator was not available for an interview. The INHA said the nurse who identified Resident #1 as having new wounds should have started an investigation. They agreed that was a standard of practice. The INHA said they felt they had reviewed the resident's care multiple times in stand-up frequently and provided many approaches. The PA was interviewed on 6/18/2020 at 4:35 p.m. She said she visualized the Resident #1's wounds periodically and not with each visit. She said the physician would also visualize the resident's wounds via telehealth visits. She said the resident did have wounds on admission that were suggestive of pressure. She said the physician, nurse practitioner (NP), or physician assistant did not complete measurements of the resident's wounds. She said caring for the resident's wounds was a team effort and the nurses would provide wound care and the physician would give wound orders, but would not necessarily document all the details about the wounds to include measurements and the description and type of wound it was. She said if the physician assessed any of Resident #1's wounds visually he would document it in his report. She said typically he did not write it down if he did not look at it. She said the resident's Doppler reports a (TRUNCATED)

Based on interview and record review, the facility failed to timely follow up on a condition change and report of severe pain for one (#1) of three sample residents reviewed for pain control. Specifically, the facility failed to timely assess and treat resident #1 following increased difficulty bearing weight on the left side and a report of severe pain (8 out of 10). The facility's failure resulted in the resident experiencing unrelieved pain and a delay in transfer to the hospital for treatment of [REDACTED]. The findings include: I. Professional Reference According to Linda Skidmore Roth, (2012) Mosby's Nursing Drug Reference, 25th edition, Elsevier Mosby, St. Louis, pages 83 and 1135: -An administration of 650 mg of [MEDICATION NAME] was indicated for the treatment of [REDACTED]. -An administration of 50 mg of [MEDICATION NAME] was indicated for treatment of [REDACTED]. II. Resident Status Resident #1, age 79, was admitted to the facility on [DATE], readmitted on [DATE], and discharged [DATE]. According to the resident's face sheet, [DIAGNOSES REDACTED]. A minimum data set (MDS) assessment signed 9/12/17 indicated the resident was cognitively intact with a brief interview for mental status of 15 of 15. The resident did not demonstrate delusions or hallucinations. The resident had experienced pain which limited his activities and made it difficult to sleep at night. He received scheduled and as needed medications for the pain, and had also received non-pharmacological interventions. An initial physical therapy assessment dated [DATE] indicated the resident experienced mild pain (2 of 10) in his left hip during the session. However, the resident was able to finish the evaluation, including an assessment of his gait and balance. He was able to ambulate more than five feet with a front wheel walker. A review of the resident's Medication Administration Record [REDACTED]. The resident had no pain on seven of ten shifts. A review of the physician orders [REDACTED]. -[MEDICATION NAME] (Tylenol), two 325 mg tablets, every six hours. The medication was scheduled for 12:00 a.m., 6:00 a.m. 12:00 p.m., and 6:00 p.m. -[MEDICATION NAME] (narcotic pain medication), one 50 mg tablet, twice a day. The medication was scheduled for 11:00 a.m. and 11:00 p.m. The resident did not have an order for [REDACTED].>A review of the resident's care plan and assessments did not include documentation about his acceptable level of pain. III. Circumstances Leading to Identification of Condition Change and Severe Pain Record review and interview demonstrated the resident experienced an incident during a transfer on the morning of 9/10/17. A. Record Review A grievance report, dated 9/10/17, from the resident's family member was reviewed with the nursing home administrator (NHA) and director of nursing (DON) on 12/27/17 at 5:49 p.m. The report indicated the family member had arrived at the facility on 9/10/17 at approximately 6:00 p.m. The resident had reported to the family member that he had been injured during a transfer that morning. The resident reported he had felt severe pain in his left hip, and had felt a pop. The report also indicated the resident had remained in his room for both lunch and dinner and had received room trays. A review of clinical record for 9/10/17 from 6:00 a.m. through 3:00 p.m. found no evidence the resident was assessed for an injury to the left side or increased pain. B. Interviews and Review of Statement Attempts to contact the resident's family for an interview were not successful. The resident had been discharged to the hospital on [DATE] and did not return to the facility. Certified nurse aide (CNA) #1 was interviewed on 12/27/17 at 5:06 p.m. He stated he was not comfortable discussing the resident's situation over the phone, but stated that he had given a statement to the DON about what had transpired on the morning of 9/10/17. A review of the CNA's statement was conducted in the presence of the DON and the NHA. The statement documented the CNA assisted the resident from bed prior to breakfast on the morning of 9/10/17. Per the CNA's statement and contrary to information documented on the grievance form (see above) and the PT interview (see below), the CNA denied the resident had expressed pain and denied the resident had buckled during the transfer. Physical therapist (PT) #1 was interviewed on 12/28/17 at 1:22 p.m. The PT said the resident told her he had buckled to the left while being transferred out of bed that morning. The PT said the resident had said he experienced severe pain and feeling a pop in his left hip during the transfer. IV. Identification of Change in Weight Bearing Ability and Severe Pain A. Record Review A physical therapy note dated 9/10/17 at 2:47 p.m. indicated the resident had been seen for physical therapy on that date. The note indicated the resident had hardware removed from the left hip and experienced pain during any mobility. The resident experienced pain at an 8 out of 10 (which is considered severe pain on the standard numeric pain intensity scale) and buckled to the left on two of two attempts to stand, demonstrating decreased ability to bear weight on the left side. The note indicated therapy had been discontinued at that point as the resident was in too much pain to continue. B. Interview PT #1 was interviewed on 12/28/17 at 1:22 p.m. The PT confirmed she had seen Resident #1 on 9/10/17 for an evaluation following a readmission from the hospital. She said she had attempted to assist the resident to stand up twice during the therapy session, and that both times the resident had buckled to the left and had not been able to bear weight. The PT said she had not previously assessed or worked with the resident, but confirmed that it was her understanding that he had been able to bear weight previously. She said the resident had grimaced during the attempts to stand and had verbalized to her that he was experiencing pain at a level of 8 out of 10. She said the therapy session had to be stopped because the resident was in too much pain to participate. V. Failure to Timely Assess Change to Left Side and Follow up on Reported Severe Pain Record review and interviews revealed facility staff was aware the resident had experienced severe pain and the inability to bear weight on the left side as early as 2:47 p.m. on 9/10/17; however, timely follow-up of these changes was not evidenced. The resident received an order for [REDACTED]. A. Record Review 1. Grievance Report The 9/10/17 grievance report from the resident's family member documented the resident had said he had notified facility staff that he was in pain earlier in the day but his pain had not been addressed. 2. Medication Administration Record The September 2017 MAR indicated [REDACTED] -The resident did not have orders for, or receive any as needed or one time only administrations of pain medication to address the 8 out of 10 severe pain experienced during the 9/10/17 at 2:47 p.m. therapy session. -The resident received his scheduled 650 mg administration of [MEDICATION NAME] (effective for mild to moderate pain, see professional reference above) at 6:00 p.m., more than three hours after the observed severe pain in physical therapy. -The resident received his scheduled administration of [MEDICATION NAME] 50 mg (effective for mild to moderate pain, see professional reference above) at 11:00 p.m., more than eight hours after the therapy session when severe pain was identified. The resident did not receive any medication administrations approved for the treatment of [REDACTED]. 3. Once Per Shift Pain Scale The per shift pain scale for the 9/10/17 documented: -On the day shift on 9/10/17 (6:00 a.m. to 6:30 p.m.) the resident experienced pain at 4 of 10. It was not possible to determine at what time the resident's pain was assessed on the day shift. -The pain scale for the night shift (6:00 p.m. to 6:00 a.m.) indicated the resident experienced pain at 5 out of 10. It was not possible to determine at what time the resident's pain was assessed on the night shift. (See resident status review above showing the resident had three reports of mild to moderate pain over ten shifts prior to 9/10/17.) Because the facility had not identified a tolerable level of pain for the resident (see resident status above), it was not possible to determine if pain at a 4 out of 10 or 5 out of 10 was acceptable to the resident. 4. Nursing Notes A nursing note dated 9/10/17 at 3:39 p.m. did not document an assessment of the buckling during therapy or of the increase in pain observed during therapy. A nursing note dated 9/10/17 at 10:58 p.m. indicated the resident had reported he was experiencing pain in his hip to his family, and an x-ray had been ordered. A nursing note dated 9/11/17 at 12:44 a.m. indicated the x-ray had demonstrated findings of an acute displaced left femoral neck (part of the hip) fracture. The resident was transported to the hospital. 5. Telephone Orders The 9/10/17 and 9/11/17 telephone orders did not evidence any orders for as needed pain medication to address increased pain. B. Interviews The DON and NHA were interviewed on 12/27/17 at 5:46 p.m. They said in response to the grievance filed by the resident's family member, they had interviewed CNA #1, licensed practical nurse (LPN) #1, and registered nurse (RN) #1, who was the unit manager. They said LPN #1 was temporary staff from a staffing agency. They said they had noted the documentation on the MAR indicated [REDACTED]. They said RN #1 and LPN #1 had each indicated they assumed the resident's pain was from his previous hip concern and no further assessment of the pain was conducted. The DON and NHA reported education had since been provided to the nurses on doing a thorough assessment of what was causing the pain for each pain report. PT #1 was interviewed on 12/28/17 at 1:22 p.m. She said when a resident experienced pain during physical therapy, the facility's process was that therapy communicated the pain verbally to the resident's nurse so that the nurse could conduct an assessment and provide treatment if appropriate. The PT said she had followed the facility process and had communicated verbally with the resident's nurse, LPN #1, who she said was a temporary agency staff, about the resident's pain and buckling to the left. She said she did not remember if she had also relayed the resident's concerns about the transfer that morning. She confirmed the communication with the LPN #1 about the pain and left-sided buckling was not documented in the therapy notes. LPN #1 was not available for interview. The DON and NHA were interviewed on 12/28/17 at 5:00 p.m. The DON said when a resident experienced pain during therapy, the therapy staff were supposed to report the pain verbally to the nursing staff so an assessment could be initiated and appropriate pain management implemented. The DON confirmed no pain assessment had been initiated following the therapy session at 2:47 p.m. The DON agreed the nursing staff initiated a pain assessment when the resident's family had come in to visit him several hours later and the family reported the resident was experiencing pain to the unit manager. The DON stated that the night shift staff had not been aware of the resident's pain concerns until the family reported the resident's pain. The DON stated if the therapist had communicated the resident's severe pain to the nurse, he would have expected to see documentation of the concern, along with a follow-up assessment and intervention in the nursing notes. He said that if the PT had not communicated the pain, she should have done so to ensure nursing staff were aware of the pain and could follow up appropriately. He said that because of the lack of documentation, both in the nursing notes and in the therapy notes, it was not clear whether that communication had taken place.

Based on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for four of 13 sample residents (#1, #9, #10 and #11) and three supplemental sample residents (#17, #21 and #26). Specifically the facility failed to ensure residents, including residents #1, #9, #10, and #17 had appropriate assessments and physician's orders [REDACTED]. The findings include: 1. IMMEDIATE JEOPARDY A. IMPOSITION OF IMMEDIATE JEOPARDY Record review revealed none of the above residents had been evaluated for safety risks with the use of the bed side rail and/or assist bar, care planned for safety, or had orders for bed side rail and/or assist bar use. Following observations and record review, completed on 6/7/10 at approximately 3:25 p.m., the findings were reported to the Centers for Medicare and Medicaid Services. It was determined that the residents' use of bed side rails and/or assist bars without safety assessments, care plans or orders for use, as well as the observed gaps between mattresses and rails and/or bars, created a situation of immediate jeopardy for serious harm to four residents (#1, #9, #10, #17). On 6/7/10 at 4:39 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were notified that the failures above created a situation of immediate jeopardy for serious harm. B. FACILITY PLAN FOR REMOVAL OF IMMEDIATE JEOPARDY On 6/9/10 at 3:25 p.m., the NHA provided a copy of the facility's POC to remove the Immediate Jeopardy. The POC read as follows: Plan of Correction "June 9, 2010 PLAN TO REMOVE IMMEDIATE JEOPARDY The following residents shall have side rails or canes removed from their beds by 5:30 PM June 7, 2010. (Resident #10) (Resident #17) (Resident #9) (Resident #1) Frequent checks for safety, utilizing Hi-Lo beds and placement of pads will ensure resident safety is maintained. Staff will immediately be made aware, as well as subsequent shifts, of the potential need to provide additional mobility assistance. 2-hour checks on these residents will be initiated. The following is the overall plan to assess, obtain consent, physician order [REDACTED]. The current canes will not be reused as bed assistive devices. Our preference will be to use side rails due to their stability. We will consult with a manufacturer on possible alternatives. All bed adaptive devices were removed on June 7, 2010, from beds of all residents who had them in place with the exception of three who refused to have them removed. These three residents will be assessed and educated for continued appropriate use of the bed adaptive device according to the procedure outlined below by the end of the day June 9, 2010. All other residents who had their bed adaptive devices removed will be assessed and a determination made as to the necessity and appropriateness of their use and documented by June 10, 2010 by noon and quarterly thereafter. The results of all assessments will be included in the resident's care plan. Residents and family members will be educated on the safe use of bed assistive devices and documented on the Risk Benefit Statement before installing the bed assistive device. Ongoing monitoring of those residents with bed assistive devices will be accomplished through both a facility wide log of all residents using a bed adaptive device and a daily monitoring log will be maintained to ensure that there are no entrapment zones, that the device is working properly - secure and not wobbly - and that the mattress is stable and cannot be moved to create and entrapment zone. Nursing staff will be educated on the risks associated with the use of bed adaptive devices, alternatives to their use and the policy and forms. This will be accomplished by in-servicing staff at the beginning of each shift and continuing until all staff is in-serviced, but no later than June 10, 2010. We will also in-service all staff including dietary to the risks and what they should monitor on beds with bed assistive devices and accomplish this by the beginning of their next schedule shift but no later than June 10, 2010. A safety assessment will be completed at admission and documented in the nursing assessment. For those residents who may benefit from a bed assistive device, a Side Rail Assessment form will be reviewed by the IDT (Interdisciplinary Team) care team. If a bed assistive device is recommended, the Risk benefit Statement by the resident and signature by the physician, social worker and registered nurse before implementation of a bed assistive device. A physician's orders [REDACTED]. A Bed Adaptive Device Log will be maintained that contains all information about the bed adaptive device utilized. The day shift charge nurses will be trained on the completion of the form and will complete the log on each day shift. The Director of Nursing will train the charge nurses on the correct completion of the form and will assure that it is done appropriately. This will include resident name, room number, dates of assessments and dates of approval of device by the care team. There will be a review to ensure that no devices are utilized without a valid physicians order for a valid physical need. Date of the order and [DIAGNOSES REDACTED]. Daily rounds by nursing staff will check on proper placement and use of the assistive device, to ensure that no entrapment zones are present and that the device is installed and functions correctly. This will be tracked on the Bed Device Monitoring log. The Medical Director will periodically in-service staff on the principles of bed safety and issues revolving around safe use of bed adaptive devices. At each meeting of the Quality Assurance Committee, a report outlining how many residents were evaluated for bed assistive devices will be given. The Bed Device Monitoring log will be presented showing that 1) assessments were done with date of completion; 2) how many residents have a bed assistive device in place; 3) for those with a bed assistive device, that re-assessments are completed on a quarterly basis (or sooner with a change in condition) as part of the care planning process; 4) the Medical Director will round quarterly with the Director of Nursing and the Administrator to inspect all beds that have such assistive devices." C. PROGRESS TO REMOVE IMMEDIATE JEOPARDY A list of "Residents for whom side rails/bed canes were removed" was provided by the facility on 06/09/10 at approximately 9:00 a.m. The list was incomplete, per initial observations by the survey team on 06/07/10. The DON provided a revised and correct list on 06/09/10 at 10:04 a.m. Review of the assessments and associated documentation, completed by the facility on 06/10/10 at 12:08 p.m., showed the following results: - Three residents had increased mobility and assistive bed devices were no longer indicated. - 12 residents used assistive bed devices to feel safe and/or the residents had poor safety awareness and assistive bed devices were not recommended. - Six residents kept or received modified assistive bed devices. By conducting a thorough resident assessment, the facility was able to greatly reduce the number of inappropriate assistive bed devices being used. D. REMOVAL OF IMMEDIATE JEOPARDY On 6/10/10 at 12:23 p.m., the NHA and DON were notified that the immediate jeopardy had been removed at 12:19 p.m. on this date; however, deficient practice remained at a scope and severity of an E (potential for more than minimal harm at a pattern). 2. PROFESSIONAL REFERENCES The 2010 "Falls in Long Term Care" website, referenced on 6/16/10 at http://www.fallsinltc.ca/physicalrestraints/siderails.htm reads, in pertinent part: "...When planning resident care: The use of bed rails should never be automatically considered as they may pose as hazards to patient safety. Nurses should evaluate the risk of using bed rails compared to not using them. Decisions to use or to discontinue use of bed rail should be made according to the individualized patient/resident assessment along with interdisciplinary team and input from resident and family. If bed rail(s) must be used: -include in the resident's chart a risk-benefit assessment that identifies why other care interventions are not appropriate or effective, -include documentation that describes attempts to use less restrictive care interventions and their failure to meet patient's assessed needs, -educate resident and family on bed rail risks and benefits, -reassess resident's needs and re-evaluate equipment if an episode of entrapment occurs... As well, if bed rails are required, then staff should pay close attention to the design of the rails and its relationship with other parts of the bed: The bars between the bed rails should be closely spaced to prevent entrapment. Space between bed rails and mattress and space between headboard and mattress should be filled to prevent patients from falling in between. Latches securing bed rails should be stable. Maintenance and monitoring of bed, mattress, and accessories should be ongoing... The assessment should cover the following areas: -Review of resident history, staff reasons for using side rails, health care records, and incident reports. -Physical examination, -Environmental characteristics of resident's bedroom and bathroom, -Identification of resident-specific problems... History: Resident/Staff Determine resident's and family's views of side rails. Note whether side rails promote patient's independence in bed or create problems. Educate resident on the benefits and risks of side rails and after demonstration of an understanding, he or she should sign a consent form to confirm preference of side rails. Nursing homes should not be compelled to use side rails based on the interests of the family. Identify staff's reasons for side rails. Resident/Staff Interview Assess patient's mental status. Determine if there are sleep problems and if yes why they occur. Describe patient's mobility at night, check for situations that increase injury risk such as trying to climb over bed rails. Determine the number of times the resident goes to the bathroom at night and whether the frequency of urination has changed due to bed rails. Determine reports of pain. Record Review Look at the patient's medical [DIAGNOSES REDACTED]. Look at the patient's medications as some drugs are strongly correlated with fall risk and should therefore be reviewed. Determine the circumstances of all falls. Physical Examination Determine patient's Body Mass Index or stature: small stature increases likelihood of slipping through or between side rails and increased BMI may prevent fall-related injury because of the shock-absorbing capacity of muscle and fat. Measure patient's lower leg length and whether they are equal. Take patient's blood pressure and radial pulse. Examine skin turgor, an indicator of dehydration, by lifting a skin fold and observing the speed with which it returns to place. Check resident's vision and perception of light. Check resident's range of motion of major joints. Evaluate resident's feet, balance and gait, and muscle strength. Describe site and intensity of pain. Environmental Characteristics Bedroom assessment: assess firmness of the mattress, assess bed height compared to patient's lower leg length, evaluate furniture in patient's room (whether it acts as barrier), and determine distance from bed to bathroom. Observe lighting conditions at night and make sure patient is able to turn on lights... The use of side rails, similar to physical restraints, can be safely reduced by a comprehensive assessment process." 3. STAFF INTERVIEWS The Medical Director (MD) was interviewed on 06/07/10 at 3:43 p.m. He stated the facility needed to have and follow a policy and procedure for side rails/bed canes to ensure appropriate use and safety. According to the MD, resident and bed assessments would be expected for all residents with side rails/bed canes prior to implementation of the device. The MD confirmed that there was "an entrapment potential there (with the side rails on resident #9's bed)." The MD stated though he and the facility staff were aware the side rails and bed canes needed to be addressed, they had not focused on the issue yet. On 6/7/10 at 4:05 p.m., the DON stated she was unable to locate a policy regarding the use of side rails. The DON was asked about the location of side rail/bed cane assessments in the resident medical records. She stated she had looked at the admission charting guidelines and could not find it, "It would have to be under assessments (tab) in the chart." The DON stated that many beds had existing side rails when the resident was admitted but that if the facility was going to implement side rails, the Interdisciplinary Team (IDT) would discuss it and communicate to the MDS Coordinator (MDSC); maintenance was responsible for putting side rails/bed canes on the beds. According to the DON, she did not consider bed canes a side rail in the past. According to the DON, "(ED) told me a few weeks ago to make a huge effort to get rid of all of those (side rails) as we could. It's on my plate, but not at the top." Regarding the inconsistent physician orders [REDACTED]." The MD was interviewed on 06/07/10 at 7:40 p.m. and provided one of two packets of information being used to inservice staff on side rail safety. The MD stated every staff member was being given copies of the two restraint documents. During interview on 06/09/10 at 10:34 a.m. with the ED, he stated the facility had "figured out how to attach mattresses to bed frames if resident have canes or side rails." 4. RESIDENT FAILURES A. Resident #9 Sample resident #9, age 93, was admitted to the facility's special care unit for residents with dementia on 6/17/09 with diagnoses, according to the face sheet, of Alzheimer's disease, gastrointestinal hemorrhage, diabetes mellitus, pulmonary obstruction, asthma, anemia, constipation, congestive heart failure, [DIAGNOSES REDACTED], and muscle atrophy. The 4/19/10 quarterly minimum data set (MDS) assessment documented the resident had short- and long-term memory problems and moderately impaired decision-making skills. She was sometimes able to make herself understood and usually able to understand others. The resident experienced periods of restlessness and exhibited repetitive physical movements. She was independent with bed mobility and required supervision with transfers. The resident had no limitation of her functional range-of-motion and no loss of voluntary movement. She was incontinent of bowel and bladder, had a urinary tract infection in the last 30 days, and had fallen in the past 30 days and the past 31 to 180 days. The resident had conditions which made her cognitive, activity of daily living, mood, or behavior patterns unstable. The resident was five feet, two inches tall and weighed 135 pounds. She resided on a special care unit for residents with dementia. According to the assessment, the resident did not use restraints and did not use side rails for bed mobility or transfers. She required partial physical assistance with standing balance. 1. Observations On 6/7/10 at 9:25 a.m., the resident's bed was observed. The resident was not in the room. The bed had a bolstered mattress and a half side rail on the left side. Between the side rail and the mattress was a seven-inch gap. On 6/7/10 at 12:45 p.m., the special care unit nurse and the director of nursing (DON) were observed to assist the resident with getting into bed. The left half side rail was on the bed, and the large gap between the mattress and the rail was still present. A small throw pillow had been stuffed into the gap, which covered approximately 1/3 of the gap. Though the resident could stand independently, she required cueing and assistance to be guided onto the bed. Once the resident was laying on the bed, both staff members assisted the resident to reposition in bed; the resident did not use the side rail for repositioning. On 6/7/10 at 3:10 p.m., the resident was observed lying in bed in her room. The side rail was attached to the bed and the seven-inch gap remained between the mattress and the rail. 2. Record Review Review of the resident's paper and computerized medical records on 6/7/10 revealed: -There was no assessment of the resident's need for and safety with side rails. -There was no assessment of the bed environment to ensure gaps and other entrapment hazards were minimized. -The 6/10 computerized physician orders [REDACTED]. -There was no consent form signed by the resident's responsible party acknowledging the risks involved with the use of side rails. -The 5/12/10 monthly nursing summary documented the resident had impaired memory and decision-making skills, was independent with bed mobility and transfers, and was incontinent. "Bed rails used" was not checked under the "Modes of Transfer and Locomotion" section. -The 5/27/10 fall risk assessment documented the resident had fallen three or more times in the past month, had an unstable gait while walking, was ambulatory and incontinent, used predisposing medications, and had predisposing diagnoses. The resident scored 16, indicating she was at high risk for falls. -The 4/20/10 interdisciplinary plan of care documented the resident required assistance with toilet use, dressing, personal hygiene, eating, and bathing; was at high risk for falls; took diuretic medications; had a diminished ability to communicate with others; was incontinent of bowel and bladder; and had a history of [REDACTED]. 3. Staff Interviews On 6/7/10 at 12:45 p.m., the DON stated the resident was able to use the side rail to assist her with bed mobility. The DON stated she had not noticed the gap between the mattress and the side rail, but agreed it was a large gap that posed an entrapment risk. The DON stated she was unsure of the facility's policy regarding the use of side rails, but would provide the information. On 6/7/10 at 3:12 p.m., certified nurse aide (CNA) #1 stated the resident was able to move independently and she sometimes used the side rail to assist with mobility. The CNA also stated the resident was able to get in and out of bed independently, though she required supervision to do so because she was confused and unsteady while transferring. The CNA stated the resident got out of bed many times throughout the night; the facility had implemented a bed alarm to alert them to her attempts to self-transfer. 4. Facility Follow-Up On 6/7/10, the resident's half side rail was removed after the above findings (lack of assessment, physician's orders [REDACTED]. The facility also conducted an adaptive device assessment on 6/10/10 in response to the surveyor's concerns. The 6/10/10 assessment documented the resident was unable to recognize potential entrapment situation and to take action to avoid them due to poor motor planning skills. The entrapment risks outweighed the benefits of the side rail. Bed rails were not indicated at this time. B. Resident #10 Sample resident #10, age 75, was admitted to the facility's special care unit on 12/2/08 and re-admitted on [DATE] with diagnoses, according to the face sheet, of Alzheimer's disease and dysthymic disorder. The 6/2/10 quarterly MDS assessment documented the resident had short- and long-term memory problems and moderately impaired decision-making skills. She was rarely/never able to make herself understood and rarely/never able to understand others. She experienced periods of lethargy and periods of restlessness, and her mental function varied over the course of the day. She exhibited repetitive physical movements, wandering, disruptive behaviors, and resistance to care. The resident was independent with bed mobility and required supervision with transfers. She required partial physical assistance with seated and standing balance. The resident did not have limited functional range-of-motion or loss of voluntary movement. She was continent of bowel and occasionally incontinent of bladder. She was five feet, five inches tall and weighed 149 pounds. The resident had fallen in the past 30 days and the past 31 to 180 days and had conditions which made her cognitive, activity of daily living, mood, or behavior patterns unstable. She resided on a special care unit for residents with dementia. According to the assessment, the resident did not use restraints and did not use side rails for bed mobility or transfers. 1. Observation On 6/7/10 at 9:17 a.m., the resident's bed was observed. The resident was not in the room. The bed had a bolstered mattress and a right half side rail with a three-inch gap between the mattress and the bed. 2. Record Review Review of the resident's paper and computerized medical records on 6/7/10 revealed: -There was no assessment of the resident's need for and safety with side rails. -There was no assessment of the bed environment to ensure gaps and other entrapment hazards were minimized. -The 6/10 CPOs did not document a physician's orders [REDACTED]. -There was no consent form signed by the resident's responsible party acknowledging the risks involved with the use of side rails. -The 5/17/10 monthly nursing summary documented the resident had impaired memory and decision-making skills, experienced periods of restlessness, was independent with bed mobility, required supervision with transfers, and was frequently incontinent. "Bed rails used" was not checked under the "Modes of Transfer and Locomotion" section. -The 5/17/10 monthly nursing summary also documented the resident had one fall during 5/10, "when she rolled off her bed wrapped in bed clothes." An incident report regarding this fall was requested from the facility, but was not received prior to exit. -A 5/27/10 physician's note documented the resident had seizure disorder. She had suffered large seizures in 12/09 and 5/10 and had several smaller seizures in between. -The 5/28/10 fall risk assessment documented the resident was disoriented at all times, had fallen three or more times in the past month, was ambulatory and incontinent, used predisposing medications, and had predisposing diagnoses. The resident scored 16, indicating she was at high risk for falls. -The 3/15/10 interdisciplinary plan of care documented the resident required assistance with toilet use, dressing, personal hygiene, eating, and bathing; was at high risk for falls; received psychoactive medications daily; required supervision/cueing to transfer; had a diminished ability to communicate with others. The care plan did not address the resident's use of a right half side rail. 3. Staff Interview On 6/7/10 at 3:12 p.m., CNA #1 stated the resident was independent with bed mobility, but required supervision with transfers in and out of bed because she was unsteady. She stated the resident often attempted to transfer in and out bed independently. 4. Facility Follow-Up On 6/7/10, the resident's half side rail was removed after the above findings (lack of assessment, physician's orders [REDACTED]. The facility also conducted an adaptive device assessment on 6/10/10 in response to the surveyor's concerns. The 6/10/10 assessment documented the resident was unable to recognize potential entrapment situation and to take action to avoid them. The entrapment risks outweighed the benefits of the side rail. Bed rails were not indicated at this time. C. Resident #17 Supplemental Sample resident #17, age 89, was admitted to the facility's special care unit on 6/24/09 with diagnoses, according to the face sheet, of hip fracture, urinary tract infection, hypertension, dementia, and muscle atrophy. The 3/31/10 quarterly MDS assessment documented the resident had short- and long-term memory problems and moderately impaired decision-making skills. She was sometimes able to make herself understood and sometimes able to understand others. The resident experienced periods of restlessness and exhibited repetitive physical movements. She was independent with bed mobility and required supervision with transfers. The resident had limitation of her functional range-of-motion in both legs but had no loss of voluntary movement. She was incontinent of bowel and bladder and had conditions which made her cognitive, activity of daily living, mood, or behavior patterns unstable. The resident was five feet, four inches tall and weighed 137 pounds. She resided on a special care unit for residents with dementia. The resident did not use restraints and did not use side rails for bed mobility or transfers. She required partial physical assistance with standing balance. 1. Observation On 6/7/10 at 9:01 a.m., the resident's bed was observed. The resident was not in the room. The bed had a bolstered mattress and a bed cane on the right side. There was a two-inch gap between the bed cane and the mattress. The bed cane wobbled back and forth, and was able to be moved to create a four-inch gap between it and the mattress without adjusting the position of the mattress. 2. Record Review Review of the resident's paper and computerized medical records on 6/7/10 revealed: -There was no assessment of the resident's need for and safety with a bed cane. -There was no assessment of the bed environment to ensure gaps and other entrapment hazards were minimized. -The 6/10 CPOs did not document a physician's orders [REDACTED]. -There was no consent form signed by the resident's responsible party acknowledging the risks involved with the use of a bed cane. -The 5/4/10 monthly nursing summary documented the resident had impaired memory and decision-making skills, experienced periods of restlessness, was independent with bed mobility and transfers, and was incontinent. "Bed rails used" was not checked under the "Modes of Transfer and Locomotion" section. -The 5/28/10 fall risk assessment documented the resident was disoriented at all times, had not experienced any recent falls, had a balance problem while standing and walking, was ambulatory and incontinent, used predisposing medications, and had predisposing diagnoses. The resident scored 20, indicating she was at high risk for falls. -The 3/29/10 interdisciplinary plan of care documented the resident required assistance with toilet use, dressing, personal hygiene, eating, and bathing; was at high risk for falls and had poor safety awareness; was frequently incontinent and was at risk for skin breakdown; received an antidepressant daily; and had a diminished ability to communicate with others. The care plan did not address the resident's use of a right bed cane. 3. Staff Interviews On 6/7/10 at 3:12 p.m., CNA #1 stated the resident was independent with bed mobility, but required supervision with transfers in and out of bed because she was unsteady. She stated the resident often attempted to transfer in and out bed independently. On 6/7/10 at 4:05 p.m., the DON stated the resident's bed cane should have been securely attached on the bed so it did not wobble and create a hazard. 4. Facility Follow-Up On 6/7/10, the resident's half side rail was removed after the above findings (lack of assessment, physician's orders [REDACTED]. The facility also conducted an adaptive device assessment on 6/10/10 in response to the surveyor's concerns. The 6/10/10 assessment documented the resident was unable to recognize potential entrapment situation and to take action to avoid them. The entrapment risks outweighed the benefits of the bed cane. A bed cane was not indicated at this time. D. Resident #1 Sample resident #1, [AGE] years old, was admitted to the facility on [DATE]. The medical [DIAGNOSES REDACTED]. The resident resided on the special care unit. According to the 4/1/10 MDS, the resident had short- and long-term memory impairments and required supervision with transfers. The resident was independent with bed mobility. The resident required minimal assistance with ambulation and portrayed behaviors such as wandering, resistance to care and verbal abuse. The resident weighed approximately 125 pounds and was 5'9" tall. The resident was not interviewable. Observations of the resident, on 5/28/10 at 9:30 a.m. and 9:57 a.m., showed he required assistance with transfers, had a safety alarm (to alert staff if he attempted to self transfer) and was ambulatory with staff assistance. The resident was thin in appearance. Observations of the resident's room, on 6/7/10 at 8:50 a.m. and 9:05 a.m., showed he resided in a single room. There was a high/low adjustable bed with a bed alarm attached (for resident safety to alert staff if he attempted to get up out of bed without assistance). The mattress was lipped around all four edges of the bed. On the left side of the bed (facing the bed), there was a bed cane. This bed cane was connected to a piece of plywood placed under the mattress. The whole apparatus, bed cane device and plywood moved with any pressure on the cane (there was no stop mechanism on the cane to keep it locked in an upright position with pressure applied towards the mattress). A 3-1/2 inch gap was measured between the edge of the mattress and the bed cane. The mattress was angled slightly to the left with the "foot end" jetting out over the support on the right hand side. On 6/7/10 at 10:59 a.m., the resident's nurse stated the resident utilized the bed cane about 50% of the time. Review of the medical record revealed no safety assessment regarding the use of the bed enabler, risk benefit statement or care plan. On 6/7/10 at 1:10 p.m., the surveyor requested the information from the Director of Nursing (DON). The DON stated she would look for the assessment. The DON continued the bed canes were not on the beds automatically. Through a nursing assessment, the resident's needs would be identified. If a device was needed, maintenance would apply the safety device to the bed. After alerting the administration about the safety issue, as noted above, the facility removed the resident's bed cane. On 6/9/10 at 10:29 a.m., the DON stated there was no safety assessment for this resident. The DON continued the facility was unaware a safety assessment was needed for a bed cane. On 6/10/10, the facility provided an adaptive bed device assessment. The assessment indicated his assist needs varied. The resident was unable to recognize potential safety concerns with the use of a bed cane. The conclusion was the bed cane was not indicated as the resident was unable to recognize potential entrapment situations and to take actions to avoid them. E. Resident #21 Supplemental sample resident #21, [AGE] years old, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review revealed the resident did not yet have an MDS completed. Review of the care plans, provided by the facility on 06/10/10, revealed there were no care plans associated with the 1/3 side rails observed on both sides of her bed (see observations below). 1. Observations On 6/7/10