Every finding on record at Vista Ridge Care and Rehabilitation

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures.Specifically, the facility failed to ensure food was palatable and served at the appropriate temperature. Findings include:I. Facility policy and procedureThe Food and Nutrition Services policy, revised October 2017, was provided by the dietary supervisor (DS) on 9/25/25 at 12:20 p.m. It read in pertinent part, Each resident would be provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Reasonable efforts would be made to accommodate resident choices and preferences. Food and nutrition services staff would inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature.''II. Resident group interviewA group of four residents (#20, #24, #63 and #80) who were assessed by the facility to be interviewable, requested to speak to a surveyor immediately after lunch on 9/23/25 at 1:05 p.m. The residents said dessert was hard. They said they could not break it up as it was too hard to eat.Resident #24 said she ate in the main dining room, but the food was usually cold when served. She said the dessert for lunch today was a lemon bar, but she could not break it up to eat it. She said if it were thrown at someone, it could knock a person out.Resident #80 said she had only been at the facility a little over a week and felt the food could be served warmer. She said the lemon bar at lunch was as hard as a rock.Resident #63 said the lemon bar dessert served at lunch was inedible because it was too hard to eat. She said her lunch was not served warm.Resident #20 said her lunch was not warm and the dessert was hard at lunch today. She said she could not eat hard food because it hurt her teeth. She said she could not eat the lemon bar.III. Resident interviewsResident #20 was interviewed on 9/24/25 at 9:10 a.m. Resident #20 said the food was always served cold. Resident #20 said she had difficulty chewing some of the food that was served Resident #63 was interviewed on 9/24/25 at 9:22 a.m. Resident #63 said the food was served cold.Resident #24 was interviewed on 9/24/25 at 4:51 p.m. Resident #24 said the food was served cold.IV. ObservationsOn 9/23/25, the lunch menu included a dinner roll, dijonnaise roasted pork loin, O'Brien potatoes, broccoli and cauliflower and lemon bar for dessert. -Several residents complained that the lemon bars were hard (see the resident group interview above).On 9/24/25, the lunch menu included pretzel breadsticks, bratwurst, baby bakers and braised sauerkraut.-The pretzel breadsticks, bratwurst, baby bakers and braised sauerkraut were not covered with a lid.A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their lunch tray on 9/24/25 at 12:40 p.m.The test tray consisted of bratwurst, baby bakers, and braised sauerkraut.The baby bakers were dry and had a temperature of 115 degrees Fahrenheit (F). The potatoes were cold to the palate.The bratwurst had a temperature of 113 degrees F and were cold to the palate.The braised sauerkraut was cold to the palate.V. Staff interviewsThe dietary manager (DM) was interviewed on 9/23/25 at 1:15 p.m. The DM said the dessert on the lunch menu on 9/23/25 was a lemon bar. She said it should have had a soft texture and be moist. The DM said the lemon bar was hard and had noticed most of the residents did not consume it. She said most of the residents received an ice cream cup or pudding as a substitute.She said they would immediately offer education to the kitchen staff to ensure recipes were followed accordingly.The DM was interviewed again on 9/24/25 at 1:00 p.m. She said the duration of time the room trays stay on the carts could be shortened by training more staff to assist with meal pass to keep the food warm. The DM said having lids for the steam table in the satellite dining room, where meals were served, could help keep the food warm.The dietary supervisor (DS) was interviewed on 9/25/25 at 11:15 a.m. The DS said it was important to ensure the right food texture and taste were obtained and food was served at an appetizing temperature to avoid residents not eating their food. The DS said the dietary aides and the kitchen staff should have noticed that the lemon bars were hard. The DS said education would be provided immediately to the kitchen staff regarding food texture and temperature.

Based on record review, 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 on two of four units.Specifically, the facility failed to:-Ensure nursing staff properly performed hand hygiene during medication administration;-Ensure staff donned (put on)) when providing care for a resident who was on enhanced barrier precautions (EBP); and,-Ensure staff sanitized the Hoyer lift between residents. Findings include: I. Failure to ensure nursing staff performed hand hygiene during medication administration A. Facility policy and procedure The Hand Hygiene policy, undated, was provided by the nursing home administrator (NHA) on 9/25/25 at 2:02 p.m. It read in pertinent part, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to: after handling contaminated objects; before applying and after removing personal protective equipment (PPE), including gloves; before preparing or handling medications; and before performing resident care procedures. B. Observations During a continuous observation on 9/24/25, beginning at 10:29 a.m. and ending at approximately 10:42 a.m. licensed practical nurse (LPN) #2 was observed administering medications to Resident #14 on the Columbine unit. The following was observed: At 9:22 a.m. LPN #2 performed hand hygiene after approaching the medication cart. LPN #2 obtained Resident #14's medications LPN #2 dispensed Resident #14's ordered medications into the cup. LPN #2 poured water into the cup from a pitcher sitting on top of the medication cart. LPN #2 secured her computer and locked the medication cart. LPN #2 grabbed a pair of gloves from a box on top of the medication cart, the medication cup, a box of Prednisolone one percent (1%) eye drops (medicated antisteroidal eye drops) and the cup of water and walked into Resident #14's room. -LPN #2 did not perform hand hygiene upon entering Resident #14's room. At approximately 10:35 a.m. LPN #2 entered Resident #14's room and placed the medication cup and the cup of water on the resident's bedside table in front of her. While waiting for Resident #14 to take her medications, LPN #2 donned the pair of gloves she brought in, in preparation for administering the resident's eye drops. At 10:39 a.m. LPN #2 used her left gloved hand to grab the resident's privacy curtain and pull it closed. LPN #2 then walked to Resident #14's door and used her right gloved hand to push the door closed. LPN #2 walked back to Resident #14's side. LPN #2 removed the bottle of eye drops from the box, removed the cap from the bottle, and instilled one drop into each of Resident #14's eyes. LPN #2 placed the bottle back into its box. LPN #2 removed gloves and threw them away. LPN #2 walked out of the resident's room and returned to the medication cart. -LPN #2 failed to perform hand hygiene appropriately. During a continuous observation on 9/24/25, beginning at 11:52 a.m. and ending at approximately 12:00 p.m., LPN #1 was observed administering medications to Resident #42 on the Pavilion unit. The following was observed: At 11:52 a.m. LPN #1 obtained a bag that contained a Humalog kwikpen (a prefilled, multidose syringe of rapid-acting insulin) 100 unit per milliliter (mL) three mL syringe. LPN #1 obtained and opened an alcohol pad. LPN #1 placed the pad's wrapper on top of the medication cart, and placed the pad on top of the wrapper. LPN #1 donned a pair of gloves. LPN #1 removed the protective cap from the insulin syringe and wiped the top against the alcohol pad approximately four to six times. LPN #1 obtained a disposable needle from the medication cart and secured it to the top of the syringe. LPN #1 dialed the insulin syringe to dispense eight units of insulin. LPN #1 primed the needle with two units of insulin, leaving six units to administer per physician's order. LPN #1 removed and discarded gloves, grabbed an alcohol swab from a drawer in the medication cart and the Humalog insulin syringe, secured her computer, locked the medication cart, and walked into Resident #42's room. -LPN #1 failed to perform hand hygiene after preparing Resident #42's medication and before walking into the resident's room. At approximately 11:56 a.m. LPN #1 entered Resident #42's room. LPN #1 grabbed a pair of gloves and walked to the resident's right side. LPN #1 placed the Humalog syringe and alcohol pad on top of the resident's bedside table and donned the pair of gloves. LPN #1 opened the alcohol pad. Using her left hand, LPN #1 lightly pinched the back of Resident #42's right upper arm and used right hand to wipe an area of skin with the alcohol pad. LPN #1 discarded the alcohol pad, grabbed the insulin syringe with her right hand, and injected the resident's insulin into his right upper arm. LPN #1 removed the needle from the syringe and discarded it into a sharps contained secured to a wall in Resident #42's room. LPN #1 removed gloves and walked out of the resident's room. -LPN #1 failed to perform hand hygiene prior to putting on gloves. C. Staff interviews LPN #2 was interviewed on 9/24/25 at 11:06 a.m. LPN #2 said hand hygiene should be performed before and after resident care, before and after administering medications. LPN #2 said hand sanitizer could be used for hand hygiene, however hands needed to be washed with soap and water if they were visibly dirty. LPN #2 said proper hand hygiene was important for infection control and preventing the transmission of germs back and forth. LPN #1 was interviewed on 9/24/25 at approximately 12:00 p.m. LPN #1 said hand hygiene should be performed before and after resident care to prevent the transmission of organisms. The director of nursing (DON) and the assistant director of nursing (ADON) were interviewed on 9/25/25 at 12:11 p.m. The DON said hand hygiene should be performed before and after resident care, and more frequently as needed if a procedure was being performed. The DON said hand hygiene was important to help decrease the risk of infections and transmission of organisms. The DON said LPN #1 should have performed hand hygiene before administering Resident #42's insulin to him. The DON said LPN #2 should have removed her gloves, performed hand hygiene, and donned a new pair of gloves before administering Resident #14's eye drops. II. EBP failures A. Professional reference According to The Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDROs) (4/2/24), retrieved on 9/29/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, EBP are an infection control intervention, designed to reduce transmission of resistant organisms, that employ targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing. B. Facility policy and procedure The Enhanced Barrier Precautions policy, dated August 2022, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:58 p.m. It read in pertinent part, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Personal protective equipment (PPE) is changed before caring for another resident. Face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care (any skin opening requiring a dressing). EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk. Staff are trained prior to caring for residents on EBPs. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. PPE is available outside of the resident rooms. Residents, families and visitors are notified of the implementation of EBPs throughout the facility. C. Observations On 9/22/25 at 11:15 a.m. registered nurse (RN) #1 was at the medication cart preparing Resident #68's medication. RN #1 put on gloves and entered the resident's room. She lifted the resident's shirt and administered Resident #68's medication via her feeding tube. RN #1 flushed the feeding tube with water and exited the room. -RN #1 failed to put on a gown before administering Resident #68's medications via a feeding tube which required the use of EBP when giving care to the feeding tube site. On 9/24/25 at 11:08 a.m. licensed practical nurse (LPN) #1 entered Resident #68's room. LPN #1 put on gloves and retrieved water from the sink. She lifted the resident's shirt and flushed her feeding tube with 200 ml (milliliters) of water. She removed her gloves and exited the room. -LPN #1 failed to put on PPE prior to providing care to Resident #5, who required EBP. D. Resident representative interview Resident #68's representative was interviewed on 9/22/25 at 11:40 a.m. The representative said staff never wore a gown when doing care or when administering medications via the feeding tube. E. Staff interviews RN #1 was interviewed on 9/22/25 at 11:25 a.m. RN #1 said she was an agency nurse and worked at the facility a lot. She said she was not aware she needed to wear a gown when providing direct care to Resident #68 or when administering her medications via the feeding tube. She looked at the resident's door and noticed the EBP signage directing staff to wear gloves and a gown when providing direct care to Resident #68. She said there were no gowns stocked in the PPE cart and she would immediately restock the gown for availability to the staff. LPN #1 was interviewed on 9/24/25 at 11:15 a.m. LPN #1 said Resident #68 required staff to be careful not to introduce any organisms into her feeding tube/site and that was why she was on EBP. She said she was required to wear gloves when providing care to the resident's feeding tube site. She said she was not aware she should have worn a gown when providing direct care. She said there was signage on the door that directed staff to wear a gown. The assistant director of nursing (ADON) was interviewed on 9/24/25 at 1:55 p.m. The ADON said EBP were required for any resident who had an opening in the skin/body or a medical device to prevent the spread of infection. She said staff needed to wear a gown and gloves when providing care to Resident #68. She said staff was educated upon hire and annually on the different types of isolation as well as what PPE was required. She said she would immediately educate the staff on the proper EBP procedure. The director of nursing (DON) was interviewed on 9/25/25 at 12:00 p.m. The DON said any resident with wounds and indwelling medical devices required EBP to prevent the spread of infection. She said signage was posted at the resident's door of what type of isolation they were on as well as what PPE was required when providing direct care. She said both RN #1 and LPN #1 should have been wearing a gown when providing care to Resident #68. IIII. Shared equipment A. Facility policy and procedure The Cleaning and Disinfecting of Resident care Equipment policy, dated May 2025, was provided by the NHA on 9/25/25 at 12:58 p.m. It read in pertinent part, Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection. Non-critical items come in contact with intact skin, but not mucous membranes. These items require cleaning followed by low/intermediate-level disinfection (use of EPA (Environmental Protection Agency) -registered disinfectants) following manufacturers' instructions. Staff shall follow established infection control principles for cleaning and disinfecting reusable, non-critical equipment. Verify whether the equipment is single-use or reusable. Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident. Multiple-resident use equipment shall be cleaned and disinfected after each use. Use only EPA-registered disinfectants with kill claims for the common organisms found in the facility. If the equipment is exposed to residents on transmission-based precautions, verify the disinfectants are registered for use with the relevant organism.Verify the disinfectant is compatible with the equipment and follow manufacturer recommendations for cleaning equipment. B. Observations On 9/23/25 at 10:24 a.m. an unidentified certified nurse aide (CNA) was removing the Hoyer lift (mechanical lift used to transfer residents) from storage She pushed the lift to room [ROOM NUMBER] and entered the room. She transferred the resident into bed and exited the room. She placed the lift back into its parking spot. -The CNA failed to clean the lift after using it to transfer the resident in room [ROOM NUMBER]. On 9/24/25 at 10:55 a.m. CNA #1 removed the Hoyer lift from storage She pushed the lift to room [ROOM NUMBER] and entered the room. She transferred the resident and exited the room. She placed the lift back into its parking spot. -CNA #1 failed to clean the lift after using it to transfer the resident in room [ROOM NUMBER]. C. Staff interviews CNA #2 was interviewed on 9/24/25 at 1:36 p.m. CNA #2 said the Hoyer lift was shared with five residents who required the lift for transfers. She said the lift should be cleaned with bleach wipes after every use. She said each resident had their own transfer sling but shared the lift. CNA #1 was interviewed on 9/24/25 at 1:39 p.m. CNA #1 said the Hoyer lift was to be cleaned after every use. She said she did not clean the lift after transferring the resident in room [ROOM NUMBER] because there were no cleaning wipes on the lift where they were usually stored. The ADON was interviewed on 9/24/25 at 1:55 p.m. The ADON said the Hoyer lift should be cleaned after use. She said the residents all had individual slings and shared the lift. She said she would immediately provide education to the staff on properly cleaning the lift between resident use. The DON was interviewed on 9/25/25 at 12:00 p.m. The DON said the Hoyer lift should be cleaned after every use and deep cleaned by night shift. D. Facility follow up On 9/25/25 the ADON provided documentation indicating CNA #1 was educated on the correct procedure for cleaning the Hoyer lift as well as EBP by the ADON.

Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to: -Ensure ready-to-eat foods were handled in a sanitary manner; and,-Ensure kitchen equipment was clean. Findings include:I. Failure to ensure ready-to-eat foods were handled in a sanitary manner.A. Professional reference The Colorado Retail Food Regulations, (3/16/24) and retrieved on 9/30/25 read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: after touching bare human body parts other than clean hands and clean, exposed portions of arms; after using the toilet room; after coughing, sneezing, using a handkerchief or disposable tissue; using tobacco products, eating, or drinking; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. (2-301.15)B. ObservationsDuring a continuous observation of the lunch meal service in the kitchen on 9/24/25, beginning at 10:40 a.m.and ending at 12:05 p.m., the following was observed:Cook (CK) #1 was preparing special orders for the lunch meal. At 10:42 a.m., CK #1 opened a refrigerator and pulled out an open bag of frozen chicken fingers. CK #1 stuck his hands into the frozen bag and grabbed several chicken fingers, and dropped them in the boiling oil next to the stove.At 10:48 a.m. without performing hand hygiene, CK #1 grabbed four slices of bread, applied butter, and placed them on a skillet without gloves.At 10:52 a.m. without performing hand hygiene, CK #1 picked two burger buns without gloves and placed them on the skillet At 11:06 a.m. CK #1 used a spatula to move the slices of bread onto the surface of the food preparation table. CK #1 added cooked bacon to the buttered bread and placed his hands on top of the bread to cut it into two parts without gloves.At 11:10 a.m. CK #1 washed his hands and donned a glove on his left hand and picked up the meal tickets, flipped through the tickets with a gloved hand, and separated the tickets into parts so he could read them.CK #1 did not remove the glove or perform hand hygiene after handling the meal tickets.At 11:14 a.m. CK #1 continued to place four premade hamburger patties onto a skillet with the same gloved hand he had used to handle the meal tickets. C. Staff interviewsCK #1 was interviewed on 9/24/26 at 1:50 p.m. CK #1 said it was important to practice safe food-handling procedures to avoid contamination and transmission of foodborne illness. CK #1 said he would remember to apply gloves during food preparation times.The dietary supervisor (DS) was interviewed on 9/24/25 at 2:14 p.m. The DS said kitchen staff and dietary aides were all trained on the proper handling of ready-to-eat food. He said CK #1 should have worn gloves and ensured that ready-to-eat food was not contaminated. He said he would immediately provide on-the-spot education for CK #1 to ensure he follows the facility's food preparation guidelines.The nursing home administrator (NHA) was interviewed on 9/25/25 at 2:15 p.m. She said she would immediately offer education for all the kitchen staff on food safety and ensure that ready-to-eat foods were handled in a sanitary mannerII. Failure to ensure kitchen equipment was cleanA. Professional referenceThe Colorado Department of Public Health and Environment (2024). The Colorado Retail Food Establishment Rules and Regulations was retrieved on 9/30/25 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view. Read in pertinent part,Equipment food contact surfaces and utensils shall be clean to sight and touch. (Chapter 4-20)B. Facility policy and procedureThe Kitchen Sanitation and Cleaning policy, revised November 2022, was provided by the DS on 9/24/25 at 12:30 p.m. It read in pertinent part, The food service area is maintained in a clean and sanitary manner.All utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks.All equipment, food contact surfaces, and utensils are cleaned and sanitized using heat or chemical sanitizing solution.C. ObservationsAn environmental tour of the kitchen was conducted on 9/24/25 at 9:30 a.m. The following was observed:The kitchen had a setup that divided the space into two cooking areas: the front and back. Each of these spaces possessed its own stove. These two stoves were positioned facing the opposite sides of the room, with one stove facing the north side of the kitchen and the other facing the south side. This arrangement allowed for dual, opposing workspaces within the kitchen area.There were black and red spots around the kitchen stove facing the south side of the kitchen The wall dividing both stoves had food particles and splashes of red watery substance, which appeared to be splashes of tomato juice on the wall. The outside of the stove, positioned to the north of the kitchen, and between a steamer, was greasy.There was dried oil mixed with lint around the surfaces and surrounding edges of the steamer and the stove positioned on the north side of the kitchen. There were splashes of white substances around the food preparation table. D. Staff interviewsThe DS was interviewed again on 9/25/25 at 12:20 p.m. He said he would conduct routine oversight of the kitchen and ensure all kitchen appliances were properly cleaned and maintained. He said some dirty areas were not being used during the food preparation. He said that all areas of the kitchen needed to be clean. The DS said deep cleaning was performed once a month, and a weekly cleaning checklist was completed each week. The DS said the staff had tried cleaning the splashes on the wall around the kitchen stove several times, but were unsuccessful in getting them off the wall.The NHA was interviewed on 9/25/25 at 2:15 p.m. The NHA stated that she would immediately re-evaluate the cleanliness of the kitchen equipment with the DS and ensure that proper training and education were provided to the kitchen staff.

Based on record review and interview, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#7) of six residents reviewed for unnecessary medications out of 44 sample residents.Specifically, the facility failed to:-Ensure an as needed (PRN) psychoactive medication were discontinued after 14 days for Resident #7;-Provide documentation and rationale to justify the continued use of a PRN psychotropic medication for Resident #7; and, -Ensure a care plan was in place with monitoring and effectiveness of Resident #7's psychotropic medication. Findings include:I. Facility policy and procedureThe Psychotropic Medication use policy, dated July 2022, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:58 p.m. It read in pertinent part, A psychotropic medication is any mediation that affects brain activity associated with mental processes and behavior.Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications. Anti-psychotics, Anti-depressants, Anti-anxiety medications and Hypnotics.Consideration of the use of any psychotropic medication is based on comprehensive review of the resident. This includes evaluation of the resident's signs and symptoms in order to identify underlying causes.Psychotropic medications are not prescribed or given on a PRN (as needed) basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications are limited to 14 days. For psychotropic medications that are not antipsychotics and the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order.II. Resident #7A. Resident status Resident #7, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anxiety disorder and depression. The 8/5/25 minimum data set (MDS) assessment revealed the resident had short and long-term memory problems and her cognitive skills for daily decision-making were severely impaired per staff assessment. She was dependent on staff for all activities of daily living (ADL). The MDS assessment documented she received an antidepressant.III. Record reviewThe September 2025 CPO documented the following physician's order:Lorazepam (anti-anxiety medication) oral tablet 0.5 mg (milligrams) by mouth every four hours as needed for agitation/anxiety, ordered on 9/9/25.-The physician's order did not have a stop date.-Review of Resident #7's comprehensive care plan did not reveal a care plan related to Resident #7's use of antianxiety medication. -Review of Resident #7's electronic medical record (EMR) did not reveal documentation regarding non-pharmacological interventions that were attempted. -Review of Resident #7's EMR revealed the physician failed to document a rationale for the continued use of the PRN Lorazepam after 14 days.-Review of Resident #7's EMR did not reveal monitoring of Resident #7's behaviors or the effectiveness of the PRN antianxiety medication. IV. Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 9/25/25 at 10:09 a.m. LPN #2 said a PRN psychotropic medication order was only good for 14 days. She said after 14 days the resident needed to be reassessed by a physician for the continued use of the medication. She said the staff should monitoring Resident #7 for side effects and effectiveness of the medication. She said a care plan should have been in place for the use of the medication. The assistant director of nursing (ADON) was interviewed on 9/25/25 at 10:26 a.m. The ADON said a PRN psychotropic medication order was only good for 14 days and after the 14 days the resident needed to be assessed by the physician for the continued use of the psychotropic medication. She said Resident #7 was on hospice and the hospice agency ordered the medication. She said the staff should have monitored Resident #7 for side effects and effectiveness of the medication. She said a care plan should have been initiated when the psychotropic medication was prescribed. The director of nursing (DON) was interviewed on 9/25/25 at 12:00 p.m. The DON said any psychotropic PRN medication should only be ordered for 14 days. She said the physician's order should have a stop date for the medication. She said after the 14 days the resident needed to be reassessed by the physician for continued use. She said the psychotropic medication should have a care plan addressing the need for the medication, monitoring any adverse reactions and the effectiveness of the medication.

Based on record review and interviews, the facility failed to ensure one (#82) residents of seven residents received treatment and care in accordance with professional standards of practice out of 44 sample residents.Specifically, the facility failed to ensure staff reported a fall for Resident #82. Findings include:I. Facility policy and procedureThe Fall Guidelines policy, revised October 2010, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:58 p.m. It revealed in pertinent part, The purpose of the procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of a fall. Falls are a leading cause of morbidity (medical condition) and mortality (death) among the elderly in nursing homes. Residents must be assessed in a timely manner for potential causes of a fall. If a resident had a fall, or was found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck, spine and extremities. An incident report must be completed for resident falls in Risk Management. The incident report should be completed by the nurse and submitted to the director of nursing (DON).A post fall head to toe evaluation should be conducted by a licensed nurse. Upon completion of the evaluation the physician should be notified and new orders obtained. When a resident has a fall, notify the physician, the DON and the nursing supervisor. Report other information in accordance with the facility policy and professional standards practice.The Fall Risk Managing policy, revised July 2025, was provided by the nursing home administrator (NHA) on 9/29/25 at 4:19 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 to try to minimize complications from falling.A fall is defined as an unintentional 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.II. Resident #82A. Resident statusResident #82, age greater than 65, was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included after care following joint replacement surgery, long term use of an anticoagulant (blood thinner), chronic pain and depressive episodes. Resident #82 was a new admission and had not yet completed the minimum data set (MDS) assessment. According to the nursing admission assessment Resident #82 was alert and orientated to person, place, situation and time. She required moderate assistance with one staff member and a front wheel walker for transfers. B. Resident representative interviewResident #82's representative was interviewed on 9/22/25 at 10:27 a.m. The representative said on 9/21/25 Resident #82 was being transferred by a certified nurse aide (CNA) and was dropped. She said Resident #82 hurt her left hand and right shoulder when she fell. She said the nurse did not assess the resident following the fall. -The NHA was notified of the fall after the interview with Resident #7's representative.C. Record reviewThe fall care plan, initiated 9/20/25, revealed Resident #82 was at risk for falls. The interventions included a clutter free environment, adequate lighting, ensuring items were within reach, ensuring the call light was within reach and encouraged to use, providing appropriate footwear when transferring/ambulating, providing assistive devices as needed and reviewing information on past falls to attempt to determine cause of the falls.A nursing progress note, dated 9/22/25 at 12:32 p.m., documented Resident #82's daughter reported that yesterday (9/21/25) between 3:00 pm and 5:00 p.m. a CNA was walking the resident back to bed from the bathroom when her legs became weak and she fell back into the recliner hitting her left hand and right shoulder. A purple bruise was observed over the resident's left hand. Her right shoulder was assessed with no redness or bruising. The physician was notified and gave an order for Xrays to the left hand and right shoulder. The Xray results revealed no fractures. A fall risk assessment, dated 9/20/25, identified Resident #82 as a high fall risk.D. Staff interviewsCNA #2 was interviewed on 9/25/25 at 10:04 a.m. CNA #2 said if a resident had a fall the CNA should immediately report the fall to the nurse. She said the nurse then assessed the resident for any injuries before the resident was moved. She said if the fall was unwitnessed the staff would initiate neurological assessment for 72 hours. Licensed practical nurse (LPN) #2 was interviewed on 9/25/25 at 10:09 a.m. LPN #2 said if a resident had a fall the CNA should immediately report the fall to the nurse. She said after reporting the fall, a registered nurse (RN) would assess the resident for any injuries prior to the resident being moved. LPN #2 said the nurse then notified the physician, family and the director of nursing (DON). She said the resident would be monitored for 72 hours following the fall. The assistant director of nursing (ADON) was interviewed on 9/25/25 at 10:26 a.m. The ADON said if the CNA was transferring the resident and the resident had a fall, the CNA should immediately report the fall to the nurse. She said the nurse would assess the resident for injuries before the resident was moved. She said the interdisciplinary team (IDT) had a risk management meeting every morning and were not aware of Resident #82's fall. The DON was interviewed on 9/25/25 at 11:oo a.m. The DON said she was not aware of Resident #82's fall until it was reported to her at the start of the survey. She said the CNA should have immediately reported the fall to the nurse so an assessment could have been completed to identify any injuries. She said she immediately initiated an investigation of the fall, suspended the CNA, notified the physician, received orders for Xrays and provided education to the staff on following the facility fall policy.

Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#7) of one resident out of 44 sample residents.Specifically, the facility failed to have a system in place to monitor Resident #7's prophylactic antibiotic use.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), The Core Elements of Antibiotic Stewardship for Nursing Homes, Appendix B, retrieved online on 9/29/25 from https://www.cdc.gov/antibiotic-use/media/pdfs/Consult-pharm-11by17poster-Urinary-Tract-P.pd.Antibiotics are frequently prescribed for prolonged duration for the prevention of infection or prophylaxis in nursing homes. While antibiotic prophylaxis may reduce recurrent UTIs (urinary tract infections) in specific populations, there is no clear evidence on prevention of recurrent UTIs among nursing home residents with asymptomatic bacteriuria. Furthermore, antibiotic use carries the risk of harm to residents, including adverse drug events and increased antibiotic resistance, which argue against the use of prolonged antibiotic therapy in nursing home residents.Identify residents on prolonged antibiotic therapy for the prevention of recurrent UTI. Discuss the indications, rationale, and planned duration of prolonged antibiotic therapy with healthcare professionals to ensure that the benefits outweigh the risk of adverse drug events.II. Facility policy and procedureThe Antibiotic Stewardship policy and procedure, revised May 2025, was provided by the nursing home administrator (NHA) on 9/25/25 at 12:58 p.m. It revealed in pertinent part, The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents. Orientation, training and education of staff will emphasize the importance of antibiotic stewardship and will include how inappropriate use of antibiotics affects individual residents and the overall community. -The policy did not address prophylactic antibiotics.II. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the September 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease and stage 4 chronic kidney disease. The 8/5/25 minimum data set (MDS) assessment revealed the resident had short and long-term memory problems and her cognitive skills for daily decision-making were severely impaired per staff assessment. She was dependent on staff for all activities of daily living (ADLs).According to the MDS assessment she received an antibiotic.B. Record reviewThe July 2025 CPO documented the following physician's order:Cephalexin (an antibiotic) 500 mg. Give one capsule by mouth four times a day for UTI for 10 days, ordered on 7/28/25. The September 2025 CPO documented the following physician's order:Nitrofurantoin Macrocrystal (an antibiotic) oral capsule 50 mg (milligrams). Give one capsule by mouth at bed time for UTIs per urology (kidney specialist) as a prophylaxis (an attempt to prevent UTIs), ordered on 4/4/24. -The physician's order for Nitrofurantoin Macrocrystal did not have a stop date.-Review of Resident #7's comprehensive care plan did not reveal a care plan related to Resident #7's antibiotic medication. -Review of Resident #7's electronic medical record (EMR) did not reveal documentation that the facility was monitoring Resident #7' for adverse reactions and ethe effectiveness of the prophylaxis antibiotic. III. Staff interviewsThe assistant director of nursing (ADON) was interviewed on 9/25/25 at 10:26 a.m. The ADON said the facility followed the Mcgeer criteria when prescribing an antibiotic. She said prophylactic antibiotics were tracked on a monthly log. She said she did not know when a resident on a prophylactic antibiotic should be reassessed for effectiveness by the physician. She said all antibiotics should have a care plan and should be monitored for side effects and effectiveness. The infection preventionist (IP) was interviewed on 9/25/25 at 12:00 p.m. The IP said a prophylactic antibiotic should be reassessed for continued effectiveness. She said Resident #7 had been on her prophylactic antibiotic since April 2024 and should have been reassessed for the continued effectiveness of the antibiotic especially since she still had UTIs. The IP said when the resident started on Cephalexin the prophylactic antibiotic should have been discontinued. She said when Resident #7 was prescribed two antibiotics at the same time, which should have been a red flag to her. She said the use of prophylactic antibiotics was not mentioned in the facility antibiotic policy and the facility did not have a tracking and monitoring system in place for the use of prophylactic antibiotics.

Based on observations, record review and interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of seven sample residents were kept free from abuse. Specifically, the facility failed to protect Resident #1 from sexual abuse by Resident #6. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation Prevention policy and procedure, revised October 2022, was provided by the nursing home administrator (NHA) on 5/12/25 at 10:30 a.m. It read it pertinent part, Our facility prohibits the abuse, mistreatment, neglect, and/or exploitation of residents. We believe that all residents have the right to be free from such actions by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving our community, family members or legal guardians, friends, or any other individuals. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Retaliation by staff is abuse. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. When another resident is the alleged perpetrator of the abuse, both residents will be assessed for any injuries. Residents will immediately be separated, families and physicians notified of the event, and both residents will be monitored for further behaviors for the next eight (8) hours. The facility will consult with the resident's primary care physician (if necessary) and/or responsible party for possible interventions and adjustments to residents' care plan. II. Incident of sexual abuse of Resident #1 by Resident #6 on 3/27/25 A. Facility investigation The facility's investigation report, initiated on 3/28/25 at 11:00 a.m., was provided by the NHA on 5/13/25 at 12:18 p.m. The investigation documented that on 3/27/25 at 4:00 p.m., certified nurse aide (CNA) #4 observed Resident #6 fondling Resident #1's front private areas while they were sitting next to each other in a resident common area. -The investigation failed to document what specific areas Resident #6 was touching on Resident #1, or whether it was over or underneath Resident #1's clothing. The investigation documented Resident #1 and Resident #6 had a history of being in a long-standing relationship and were often seen sitting together, holding hands and comforting one another. It documented it was the first time facility staff were aware of increased intimacy occurring between Resident #1 and Resident #6. However, the investigation additionally documented that when Resident #1 and Resident #6 were able to consent to sexual activity, it was welcomed by both parties and continued as a normal part of their relationship. Resident #1 was interviewed by the social services director (SSD) on 3/28/25, time not documented. The SSD documented Resident #1 voiced no concerns, she could not recall the incident that occurred with Resident #6 and Resident #1 was her baseline, normal self. Resident #6 was interviewed by the SSD, date and time not documented. The SSD documented Resident #6 stated he was sorry, he would not do it any longer and that he was agreeable to keeping his distance from Resident #1. The investigation documented Resident #1 and Resident #6 were separated and monitored with frequent checks. It documented both residents' care plans were updated regarding sexual activity and their relationship. -However, no documentation was found in the investigation, or Resident #1 and Resident #6's electronic medical records (EMR), addressing both residents' behavior monitoring or that the frequent resident checks were completed. -Additionally, no updated interventions to prevent further incidents of abuse were added to Resident #1 or Resident #6's care plans after the incident of sexual abuse on 3/27/25 (see record review below). The investigation concluded the incident of sexual abuse was unsubstantiated due to the history of a relationship between Resident #1 and Resident #6. It documented the relationship had been ongoing for the last several years, and that Resident #1's family was aware and consenting to the relationship. -However, an interview with Resident #1's representative revealed he was not aware of a relationship between Resident #1 and Resident #6 or that an incident occurred between Resident #1 and Resident #6 on 3/27/25 (see Resident #1's representative interview below). -Additionally, an interview with the facility's NHA and regional clinical consultant (RCC) #1 revealed the NHA and RCC #1 were unaware of Resident #1's relationship with a former resident with the same first name as Resident #6 (see interviews below). -The investigation failed to document whether the facility investigated or confirmed with Resident #1 and/or her representative's that the previous consent for a long-term sexual relationship was with Resident #6 and/or the former resident who passed away. -The investigation failed to include a signed witness statement from CNA #4 regarding the alleged sexual abuse on 3/27/25. -Additionally, it did not include signed statements from the facility staff interviewed about the incident. The interviews were paraphrased and signed by the NHA and/or the SSD. B. Resident #1 (victim) 1. Resident status Resident #1, age 83, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (autoimmune disorder affecting the central nervous system), generalized muscle weakness, need for assistance with personal care and unspecified dementia without behavioral/psychotic/mood disturbance (cognitive decline). The 4/2/25 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory problems and she never/rarely made decisions about tasks of daily life. She needed substantial assistance with oral hygiene and transfers. She was dependent on staff for personal/toileting hygiene, showering, dressing, and bed mobility. She was always incontinent of bladder and bowel. 2. Resident representative interview Resident #1's representative was interviewed on 5/13/25 at 2:04 p.m. The representative said Resident #1 had been diagnosed with dementia and Alzheimer's disease (a progressive brain disorder), and would not know what was going on if someone attempted to touch her intimately. The representative said he was aware of a relationship Resident #1 had with a former resident in the facility, however, he said that resident (who had the same first name as Resident #6) passed away five to six years ago. The representative said he was unaware of a relationship between Resident #1 and Resident #6 and he denied being informed of the incident that occurred on 3/27/25. 3. Record review The potential for decline in mood and behavior care plan, initiated 8/27/14 and revised 2/20/18, revealed Resident #1 had the potential for decline in mood and behavior related to her diagnosis of dementia. It documented Resident #1 would often talk nonsensically and on unrelated topics, that she exhibited short-term memory deficits and needed reminding and cues to complete her daily tasks, and that she needed redirection and orientation daily. Interventions, initiated 8/27/14, included offering redirection and orientation as needed to complete daily tasks, providing comfort and support, allowing time to calm and reapproaching if she was agitated and resistive and reporting any changes in mood and behavior to nursing and the SSD. The actual mood and behavior care plan, initiated 1/19/21 and revised 3/28/25, revealed Resident #1 had behaviors of being combative during care, and she would strike out at and/or kick at staff during incontinence care. It documented Resident #1 had a consenting relationship with a male resident, that both parties welcomed the relationship without any negative consequences, and it was an ongoing relationship for both parties. -However, the care plan did not specify whether or not the consenting relationship was with Resident #6 or the other male resident who passed away. Interventions, initiated 1/19/21, included explaining care and processes while performing each step, interacting with an empathetic and supportive manner and offering one-to-one interaction as needed. -There were no updated interventions were added to Resident #1's care plan after the sexual abuse incident with Resident #6 on 3/27/25. -A review of Resident #1's progress notes did not reveal documentation addressing the incident of sexual abuse with Resident #6 on 3/27/25, what monitoring/behavior tracking was completed or what interventions were put into place after the alleged incident occurred. -A review of Resident #1's May 2025 CPO did not reveal any physician's orders for behavior monitoring for an intimate relationship or consent. -A review of Resident #1's EMR revealed there were no documented sexual consent assessments for a relationship between Resident #1 and Resident #6. C. Resident #6 (assailant) 1. Resident status Resident #6, age 65, was admitted on [DATE]. According to the May 2025 CPO, diagnoses included unspecified cerebral palsy (brain disorder that affects movement and coordination), unspecified disorder of psychological development, generalized muscle weakness, other seizures and moderate intellectual disabilities. The 2/12/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of six out of 15. He required setup assistance with eating. He was dependent on staff for oral/personal/toileting hygiene, dressing, bed mobility, and transfers. 2. Record review The mood/behavior care plan, initiated 4/7/22 and revised 5/13/25 (during the survey), revealed Resident #6 had the potential for decline in mood and behaviors related to his diagnoses of depression and intellectual and developmental disabilities (IDD). It documented Resident #6 would often hold hands and pet other peoples' arms or legs while sitting next to consenting females/males. It documented Resident #6 had a consenting relationship with a female resident and both parties welcomed the relationship without negative effects. Interventions, initiated 4/7/22, included monitoring and documenting each behavioral event, offering psychosocial support or one-to-one interaction as needed and interacting in an empathetic and supportive manner. -The care plan did not include documentation addressing an intimate or sexually active relationship between Resident #1 and Resident #6. -Additionally, no updated interventions were added to Resident #6's care plan after the sexual abuse incident with Resident #1 on 3/27/25. The cognition care plan, initiated 4/7/22 and revised 8/29/22, revealed Resident #6 had impaired thought processes and required assistance with complex decision making due to IDD diagnosis with impaired mental development. Interventions, initiated 4/7/22, included communicating with resident/family/caregivers regarding residents' capabilities and needs, cueing/reorienting/supervising as needed and monitoring/documenting/reporting any changes in cognitive function as needed. -A review of Resident #6's progress notes did not reveal documentation addressing the incident of sexual abuse with Resident #1 on 3/27/25, what monitoring/behavior tracking was completed or what interventions were put into place after the alleged incident occurred. -A review of Resident #6's May 2025 CPO did not reveal any physician's orders regarding behavior monitoring for an intimate relationship or consent. -A review of Resident #6's EMR revealed there were no documented sexual consent assessments for a relationship between Resident #1 and Resident #6. III. Staff interviews CNA #2 was interviewed on 5/13/25 at 4:01 p.m. CNA #2 said she had never observed Resident #6 inappropriately touching another resident. However, she said she had been previously told to separate Resident #6 from another resident if he was observed inappropriately touching them. CNA #2 said Resident #6 was being monitored for inappropriate touching behaviors. CNA #2 said she was unsure where behaviors were tracked, however, she said she thought the behavior monitoring could be found in the resident's EMR. CNA #2 said she could determine consent because she knew her residents and she knew who could consent and who could not. CNA #3 was interviewed on 5/13/25 at 2:43 p.m. CNA #3 said Resident #6 has previously gotten a little touchy with other residents, especially female residents. CNA #3 said facility staff tried to keep Resident #6 separated from Resident #1, however, she said Resident #6 kept going back to Resident #1. CNA #3 said Resident #6 had backed off of Resident #1 due to him taking a liking to another resident. Licensed practical nurse (LPN) #2 was interviewed on 5/13/25 at 3:18 p.m. LPN #2 said a resident's medication administration record (MAR) was where facility staff could go to determine whether a resident was on behavior monitoring and what behaviors were being monitored. LPN #2 said Resident #6 was previously being monitored for his close interactions with other residents. LPN #2 was unsure when the resident's monitoring started or stopped. Registered nurse (RN) #1 was interviewed on 5/13/25 at 3:37 p.m. RN #1 said she had never observed Resident #1 and Resident #6 together or inappropriate touching between them, but she said she had heard about it. RN #1 said she was not familiar with Resident #6, however, she said she was made aware to separate and document if she observed him touching another resident inappropriately. -However, a review of Resident #1 and Resident #6's EMRs did not reveal physician's orders, care plan interventions, or progress notes that addressed monitoring for inappropriate touching or consent (see record review above). The NHA and RCC #1 were interviewed together on 5/14/25 at 1:20 p.m. The NHA said the facility did not have a formal assessment it used to determine a resident's capacity to consent to a sexual relationship with another resident. The NHA said Resident #1 and Resident #6 could both give consent and would vocally express whether they consented to something or not. The NHA said interventions the facility put into place after the alleged incident between Resident #1 and Resident #6 on 3/27/25 included staff re-education on residents' rights to sexual expression and consent and monitoring Resident #1 and Resident #6's behaviors for signs of distress/non-consent. The NHA said any interventions should be documented in the resident's care plan. The NHA confirmed updated interventions were not documented in Resident #1 or Resident #6's care plans. RCC #1 said Resident #1's representative was aware of the resident's relationship with Resident #6 and he consented to Resident #1 having relations with other residents. RCC #1 said Resident #1 and Resident #6 used to live in the same room together a few years ago. -However, the resident's representative said Resident #1 was in a relationship previously with a resident who had passed away and the representative was not aware of a relationship between Resident #1 and Resident #6 (see Resident #1's representative interview above). The NHA and RCC #1 said they were not aware that Resident #1's representative was not aware of a relationship between Resident #1 and Resident #6 and they were unable to confirm whether or not Resident #6 was the same resident that Resident #1 had a previous consensual relationship with. The NHA, RCC #1, and the SSD were interviewed together on 5/14/25 at 2:10 p.m. The SSD said Resident #1 had had relationships with two different male residents with the same first name. The SSD said Resident #1 had a relationship with a former resident and they lived in the same room together until he passed away several years ago. The SSD said after that, Resident #1 began a relationship with Resident #6. The SSD said it had been a while since she was able to make contact with Resident #1's representative. She said she had tried contacting him multiple times, but he would not answer or return her calls or his voicemail box was full. The SSD said she did not document her attempts to contact Resident #1's representative. The facility's medical director (MD) was interviewed on 5/14/25 at 4:12 p.m. The MD said, for residents with dementia, facility staff should contact the resident's representative to determine what the resident's wishes would be if they had the capacity to consent to a sexual relationship. He said a signed agreement by both parties consenting to the relationship should be obtained. The MD said he was notified of a relationship between Resident #6 and a different resident a while ago, but he said he was not aware of a relationship between Resident #1 and Resident #6. -However, a review of Resident #1 and Resident #6's EMRs did not reveal signed consent forms for an intimate relationship for either resident (see record review above). -Additionally, Resident #1's representative denied knowledge of a relationship between Resident #1 and Resident #6 (see interview above).

Based on observations, record review, and interviews, the facility failed to ensure two (#2 and #4) of seven residents out of seven sample residents received services provided or arranged by the facility that met professional standards of quality. Specifically, the facility failed to ensure weekly skin assessments were consistently completed, per physican's orders, for Resident #2 and Resident #4. Findings include: I. Facility policy and procedure The Professional Standards policy, revised December 2024, was provided by the nursing home administrator (NHA) on 5/15/25 at 8:43 a.m. It read in pertinent part, The facility is committed to providing the highest quality of care to our residents. We believe that everyone deserves to live with dignity, respect, and the opportunity to thrive. Our goal is to foster a safe, nurturing, and supportive environment through continuous improvement in care practices. Communication and coordination of care: effective communication among all members of the care team, residents, and families will be prioritized to ensure coordinated and comprehensive care. The facility will have protocols in place for timely updates on residents' health status and any changes in care. The Skin Assessment for Breakdown policy, revised February 2025, was provided by the NHA on 5/14/25 at 11:20 a.m. It read in pertinent part, The licensed nurse will complete a weekly skin assessment to monitor for skin breakdown and pressure ulcers. Physicians will be notified of new skin breakdown, with treatment order when applicable. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included amyotrophic lateral sclerosis (neurological disorder affecting nerve cells in the brain and spinal cord causing loss of upper and lower motor neurons), subdural hemorrhage without loss of consciousness (collection of blood between the inner layer of skull and the surface of the brain), protein-calorie malnutrition (nutrition deficit) and dysphagia (difficulty swallowing). The 4/16/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff for toileting, dressing, bed mobility and transfers. The MDS assessment indicated Resident #2 was at risk for developing pressure ulcers/injuries. B. Resident interview Resident #2 was interviewed on 5/12/25 at 12:52 p.m. Resident #2 answered questions by writing answers on paper (due to her loss of motor speech abilities). Resident #2 wrote that she was not sure when her skin was looked at by nursing staff. C. Record review The skin care plan, initiated 2/13/25, revealed Resident #2 had an increased risk of skin breakdown related to impaired mobility, episodes of bladder incontinence and scleroderma. Interventions included completing weekly skin observations. Review of Resident #2's May 2025 CPO revealed the following physician's order: Document the weekly skin assessment findings on skin observation tool form every Sunday evening, ordered 4/11/25. Review of Resident #2's electronic medical record (EMR) revealed the resident had a hospital stay from 2/18/25 to 2/24/25 and again from 4/3/25 to 4/11/25. Review of Resident #2's EMR, from 2/11/25 to 5/13/25, revealed weekly skin observation tool assessments were completed and documented on the following days: 2/12/25, 3/10/25, 3/31/25, 4/13/25, 4/27/25 and 5/11/25. -Weekly skin observation tool assessments were not documented per physician's orders (see physician's order above) for the following days (excluding the two weeks the resident was in the hospital during that time frame - see above): 3/5/25, 3/17/25, 3/24/25, 4/20/25 and 5/4/25. III. Resident #4 A. Resident status Resident #4, age 82, was admitted on [DATE] and readmitted on [DATE]. According to the May 2025 CPO, diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris (a condition that restricts blood flow in the heart, without chest pain), chronic systolic (congestive) heart failure, fibromyalgia (widespread muscle pain and fatigue), generalized muscle weakness and unspecified dementia (cognitive disorder) with agitation. The 4/9/25 MDS assessment revealed the resident was moderately cognitively impaired with with a BIMS score of seven out of 15. She required substantial assistance with bed mobility and transfers. She was dependent on staff for showering and personal/toileting hygiene. She used a manual wheelchair for locomotion. She was always incontinent of bowel and bladder. The MDS assessment indicated the resident was at risk for developing pressure ulcers. B. Record review The skin care plan, initiated 8/22/22 and revised 11/29/22, documented Resident #4 was at risk for skin breakdown related to impaired mobility, obesity, wearing oxygen via nasal cannula, a pacemaker (an implanted device that monitors heart rate and rhythm), major depressive disorder, unsteady gait with poor balance, weakness, hypertension (high blood pressure), angina (chest pain), coronary artery disease (a condition affecting arteries of the heart) and incontinence. Interventions, initiated 8/22/22, included completing weekly skin observations, providing incontinence care after each incontinent episode and as needed, keeping skin clean and dry and notifying the provider and promptly implementing treatment if skin breakdown occurred. Review of Resident #4's May 2025 CPO revealed the following physician's order: Weekly skin observation every Tuesday evening shift for skin monitoring. Document findings on skin observation tool, ordered 9/5/23. Review of Resident #4's EMR, from 2/11/25 to 5/13/25, revealed weekly skin observation tool assessments were completed and documented on the following days: 2/11/25, 3/4/25, 3/11/12, 4/1/25, 4/8/25, 4/15/5, 4/22/25, 4/29/25 and 5/6/25. -Weekly skin observation tool assessments were not documented per physician's orders (see physician's order above) for the following days: 2/18/25, 2/25/25, 3/18/25, 3/25/25 and 4/8/25. IV. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 5/14/25 at 9:18 a.m. LPN #1 said residents' skin assessments were to be completed once weekly. She said an average of one to two residents per shift were scheduled for skin assessments each day. LPN #1 said skin assessments were to be documented in the residents' EMRs under the skin observation tool form. LPN #1 said it was important for skin assessments to be completed weekly to identify any issues with residents' skin timely. Regional clinical consultant (RCC) #1 was interviewed on 5/14/25 at 11:30 a.m. RCC #1 said skin assessments were to be completed weekly by the nurse and the nurses were to report any abnormal findings to the provider. RCC #1 said skin assessments were to be documented in the residents' EMRs under the skin observation tool. RCC #1 reviewed Resident #2 and Resident #4's EMRs and said both residents were missing skin observations (see record review above). RCC #1 said it was best practice to attach a schedule to flag the nurse in the EMR to ensure skin observations were not missed. RCC #1 said it appeared nurses were referring to a paper schedule for skin assessments. Registered nurse (RN) #2 was interviewed on 5/14/25 at 12:28 p.m. RN #2 said resident skin assessments should be completed twice weekly. RN #2 said the assessments were documented in the residents' EMRs. RN #2 said there was a printed schedule at the nurse's station that detailed when residents were due for skin assessments. RN #2 said an alert in the residents' treatment administration records (TAR) additionally let nurses know when residents were scheduled for skin assessments. 47064

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 (#1) of seven residents out of seven sample residents. Specifically, the facility failed to ensure physician's visit progress notes for Resident #1 were maintained in her electronic medical record (EMR). Findings include: I. Facility policy and procedure The Charting and Documentation policy, revised January 2025, was provided by the nursing home administrator (NHA) on 5/14/25 at 11:20 a.m. It read in pertinent part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT) regarding the resident's condition and response to care. The following information is to be documented in the resident medical record: -Objective observations; -Medications administered; -Treatments or services performed; -Changes in the resident's condition; -Events, incidents or accidents involving the resident; and -Progress toward or changes in the care plan goals and objectives. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. II. Resident #1 A. Resident status Resident #1, age 83, was admitted on [DATE] and readmitted [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (an autoimmune disorder affecting the central nervous system), generalized muscle weakness, need for assistance with personal care and unspecified dementia without behavioral/psychotic/mood disturbance (cognitive decline). The 4/2/25 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory problems.She needed substantial assistance with oral hygiene and transfers. She was dependent on staff for personal/toileting hygiene, showering, dressing, and bed mobility. She was always incontinent of bladder and bowel. B. Record review -A review of Resident #1's EMR revealed the last physician's visit progress note documented was in April 2024. Physician's visit progress notes for Resident #1 were provided by the NHA on 3/15/25 at 10:54 a.m. The physician's visit progress notes revealed Resident #1 was seen on the following dates: 11/24/24, 1/18/25 and 3/22/25. -However, the physician's notes were not readily accessible in the resident's EMR. III. Staff interviews The NHA and regional clinical consultant (RCC) #2 were interviewed together on 5/15/25 at 11:12 a.m. The NHA revealed the facility did away with its medical records department last fall, before she began working at the facility. The NHA said the previous NHA assigned the facility's receptionist the responsibility of scanning medical records into a resident's EMR. The NHA said medical records should be uploaded into the EMR within 24 hours of receipt. The NHA said Resident #1's physician's access to the facility's EMR was revoked in December 2024, when the physician self-terminated his role as the facility's medical director and primary physician. The NHA said the physician and Resident #1 both chose for the physician to remain Resident #1's primary provider and Resident #1 was the only resident the physician now saw at the facility. However, the physician's EMR access was not reinstated, so the physician's notes were no longer uploaded to Resident #1's EMR. The NHA said Resident #1's physician was re-granted access to the facility's EMR system on 5/15/25, during the survey. The NHA failed to mention why the physician's access was not reinstated before 5/15/25. The NHA said maintaining resident records was important because staff needed to have a full picture of what was going on with a resident.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for one (#2) of three residents reviewed for ADLs out of seven sample residents. Specifically, the facility failed to ensure Resident #2, who was dependent on staff for care, received showers per her preference. Findings include: I. Facility policy and procedure The Bath Shower/Tub policy and procedure, revised January 2025, was received from the nursing home administrator (NHA) on 5/14/25 at 11:08 a.m. It revealed in pertinent part, The purpose of this procedure is to promote cleanliness, provide comfort to the resident and observe the condition of the resident's skin. Document the date and time the shower/tub bath was performed, and the name and title of the individual who is assigning the resident with the shower/tub bath, all assessment data (any reddened areas, sores on the residents skin) obtained during the shower/tub bath, how the resident tolerated the shower/tub bath, if the resident refused the shower/tub bath, the reason(s) why and the intervention taken and the signature and title of the person recording the data. Notify the supervisor if the resident refuses the shower/tub bath. Notify the physician of any skin areas that may need to be treated. Report other information in accordance with facility policy and professional standards of practice. II. Resident #2 A. Resident status Resident #2, age greater than 65, was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included amyotrophic lateral sclerosis (neurological disorder affecting nerve cells in the brain and spinal cord causing loss of upper and lower motor neurons), subdural hemorrhage without loss of consciousness (collection of blood between the inner layer of skull and the surface of the brain), protein-calorie malnutrition (nutrition deficit) and dysphagia (difficulty swallowing). The 4/16/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. She was dependent on staff for toileting, dressing, bed mobility and transfers.She required set up assistance with eating. B. Observations On 5/12/25 at 11:45 a.m. Resident #2 was in the dining room being assisted by a family member during lunch. Resident #2's hair was slicked back into a pony tail and looked greasy and shiny. On 5/13/25 at 8:29 am Resident #2 was in the dining room sitting at the eating assistance table with four other residents and two staff members. Resident #2's hair was pulled back and was greasy, shiny and slicked back. C. Resident #2 and family interview Resident #2 was interviewed on 5/12/25 at 12:52 p.m. A family member was present in the resident's room. Resident #2 used a pen and paper to communicate due to a medical condition. Resident #2 wrote down that she had not reviewed a shower in about 10 days. Resident #2 said she would like at least one shower, at a minimum, every seven days. D. Record review The ADL care plan revealed Resident #2 required assistance with ADLs due to impaired functional ability/mobility and activity intolerance due to scleroderma. Interventions included one-person assistance with bathing. -Review of the certified nurse aides (CNA) task documentation record where the CNAs documented showers and other cares revealed there was no documentation that Resident #2 had received a shower from 4/14/25 to 5/11/25, a period of 30 days. -Review of a second CNA task documentation record from 4/14/25 to 5/11/25, where CNAs were to document if the resident received a bath each day revealed there was one documentation which indicated Resident #2 had received one shower during the 30-day period, on 4/27/25, and the resident was dependent on staff to complete. -Review of Resident #2's progress notes failed to reveal any refusals of showers by the resident. On 5/14/25 at 12:48 p.m. regional clinical consultant (RCC) #1 provided paper documentation for Resident #2's showers. According to the P-hall shower schedule, last updated 11/5/24, Resident #2 was to receive showers on Tuesday and Fridays every week. -The P-hall shower schedule was last updated prior to the admission of Resident #2. There were two showers sheets provided by RCC #1 which documented two showers out of 10 shower opportunities from 4/14/25 to 5/13/25 were provided to Resident #2, one on 4/27/25 and the second on 5/6/25. -The facility failed to provide Resident #2 with two showers a week, per the shower schedule. -Review of Resident #2's electronic medical record (EMR) revealed no documentation to indicate why Resident #2 did not receive her showers as scheduled. III. Staff interviews CNA #1 was interviewed on 5/14/25 at 9:04 a.m. CNA #1 said there was a book at the nurses station with the resident shower schedule for each hall. CNA #1 said the facility had a shower aide to provide showers to residents but the shower aide was often pulled to the floor to work as a CNA instead of providing resident showers. CNA #1 said when the shower aide had to work the floor, all CNAs working were responsible to complete showers for the residents they were assigned to. CNA #1 said the CNAs were to chart the residents' showers in the CNA charting system when they were completed. CNA #1 said CNAs were to report any skin issues noted while showering residents to the nurse or let the nurse know if a resident was refusing the shower. CNA #1 said if the resident refuses a shower they would attempt at different times to accommodate the resident but then would also involve the nurse to see if there was anything that was preventing the resident from taking the shower. CNA #1 said if the resident still refused the shower, the CNA and the nurse would chart it in the resident's EMR. CNA #1 said to his knowledge, Resident #2 did not refuse showers. Licensed practical nurse (LPN) #1 was interviewed on 5/14/25 at 9:18 a.m. LPN #1 said CNAs were to offer showers to residents on their assigned days and if the resident refused, then the CNA was to notify the nurse. LPN #1 said she would assess the resident to see if there was a reason the resident did not want the shower. LPN #1 said she would try to accommodate changes for shower times to meet residents' needs. LPN #1 said if the resident refused, she would put in a progress note in the residents' EMR. LPN #1 said it was important residents received their showers to help promote skin integrity and prevent skin break down. RCC #1 was interviewed on 5/14/25 at 11:30 a.m. RCC #1 said staff would document resident showers on a paper shower schedule and then chart the shower in residents' EMR. RCC#1 said agency staff CNAs sometimes had issues accessing the EMR to chart, so they could be charting on paper. RCC#1 said shower documentation should be completed on paper and in the EMR. RCC #1 said the facility had a bath aide to complete scheduled showers who was scheduled to work 12 hours per day from 6:00 a.m. to 6:00 p.m. RCC #1 said she was unaware the bath aide was being pulled from giving residents showers to work on the floor as a CNA. RCC #1 said if the bath aide was pulled to work the floor, then it was the responsibility of the floor CNAs to complete the showers for their assigned residents. RCC #1 said the shower schedule would document the residents' preferences for showers and it was the responsibility of the shower aides to update the schedule with resident preferences. -However, the paper shower schedule had not been updated since 11/5/24 (see record review above). RCC #1 said it was important residents received showers to promote hygiene, skin cleanliness and prevent skin breakdown.

Based on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#48 and #54) of four residents out of 33 sample residents. Resident #54 was admitted to the facility with a known risk of developing pressure wounds. The resident developed a blister on the right heel caused by poor-fitting shoes the wound started as a blister that worsened and required medical attention. The blister developed into a deep tissue pressure injury and progressed after several weeks and surgical debridement to a stage 4 pressure injury to his right heel. Once the deep tissue injury was identified the facility developed a care focus for the wound and implemented the use of cushioned bunny boots and heel floating with pillows to offload pressure off of the resident's heels to promote healing. Based on observations and interviews, the facility was not consistently providing offloading assistance to relieve pressure on the resident's heels. The stage 4 pressure injury to Resident #54's right heel was first identified as a concern on 9/16/23 and progressed to a stage 4 pressure wound on 10/18/23 the wound was still in a state of healing and is classified as unhealed. The facility's failure to implement interventions with his known risk led to Resident #54 developing a facility-acquired right heel pressure injury. In addition, the facility failed to: -Consistently provide care planned interventions to prevent the development, worsening, and re-emergence of pressure injuries for Resident #48 and Resident #54 by not consistently applying heel protector boots; -Prevent Resident #48 from developing a facility acquired stage 2 deep tissue pressure injury and reemergence of the wound, at the same location, as a neuropathic wound (a wound caused by the breakdown of skin and subcutaneous tissue due to poor neurological function of the peripheral nervous systems were pressure points cause ulceration through the epidermal and dermal tissue layers) to the left heel. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/6553d3440e18d57a550c4e7e/1699992399539/CPG2019edition-digital-Nov2023version.pdf on 12/26/23. Pressure injury classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. -Bruising indicates suspected deep tissue injury Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. Risk Factors and Risk Assessment -Consider individuals with limited mobility, limited activity and a high potential for friction and shear to be at risk of pressure injuries; -Consider individuals with a Category/Stage 1 pressure injury to be at risk of developing a Category/Stage 2 or greater pressure injury; -Conduct a pressure injury risk screening as soon as possible after admission to the care service and periodically thereafter to identify individuals at risk of developing pressure injuries; and, -When conducting a pressure injury risks assessment: Use a structured approach; Include a comprehensive skin assessment; Supplement use of a risk assessment tool with assessment of additional risk factors; Interpret the assessment outcomes using clinical judgment; Skin and Tissue assessment -Assess the pressure injury initially and as soon as possible after admission/transfer to the healthcare service; -Rre-assess at least weekly to monitor progress toward healing; -Assess the physical characteristics of the wound bed and the surrounding skin and soft tissue at each pressure injury assessment; and, -Monitor the pressure injury healing progress Support Surfaces For individuals with a pressure injury, consider changing to a specialty support surface when the individual: Cannot be positioned off the existing pressure injury. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. II. Facility policy and procedure The Pressure Ulcer/Skin Breakdown-Clinical Protocol, Skin Protection and Wound Prevention policy, revised April 2018, was provided by the director of nursing (DON) on 12/14/23 at 7:37 a.m. It read in pertinent part, The nursing staff and practitioner will assess and document an individual's risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length width, and depth, presence of exudate or necrotic tissue; pain assessment, resident mobility status, current treatments, including support surfaces, and all active diagnosis. The physician will clarify the status of relevant medical issues, whether there was a soft tissue infection or just wound colonization, whether the wound was necrotic, and the impact of comorbid conditions on healing the existing wound. The physician will order pertinent wound treatments, identify medical intervention, and help characterize the likelihood of wound healing, based on a review of pertinent factors, including, healing or prevention likely, healing or prevention possible, and healing or prevention unlikely. III. Resident #54 A. Resident status Resident #54, age greater than 60, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included non-traumatic intracerebral hemorrhage (bleeding in the brain), Alzheimer's disease and congestive heart failure. The 9/29/23 minimum data set (MDS) assessment revealed that the resident had impaired cognition and was unable to complete a brief interview for mental status (BIMS) assessment. The staff assessment of the resident's cognition revealed the resident had short and long term memory problems, was unable to recall staff name and faces, location of her room and had severely impaired ability to make decisions. The resident had moderate hearing difficulty, unclear speech and was rarely understood. The resident was dependent upon staff to put on or take off footwear and dressing. The resident needed substantial assistance from staff for transfers, toilet use, personal bathing and showering. The resident had one stage 1 pressure injury or scar over a bony prominence; was at risk of developing pressure injuries and had one unstageable pressure injury with suspected deep tissue injury in evolution that was not present upon admission. Skin and pressure injury treatments included: pressure reducing device for the resident's chair and bed; nutrition and hydration interventions; pressure injury care; and, application bandages and ointments and medications to areas other than the feet. B. Resident observations On 12/11/23 at 10:07 a.m. Resident #54 was observed. The resident was sleeping in bed on her left side; the resident's heel protector boots were sitting atop a recliner in the resident's room and were not placed on the resident's feet, as ordered (see physician orders below). -At 11:32 a.m. two certified nurse aides (CNAs) entered the resident's room with a hoyer (mechanical)lift and transferred the resident from bed to wheelchair. The resident's feet were covered with pink socks. Heel protector boots were at the foot of the bed but neither CNA put the heel protectors on the resident's feet. On 12/12/23 at 9:25 a.m. the resident was seated in a wheelchair across the nurses station. The resident had slippers on her feet. The slippers offered no cushioning to protect the resident heels from the foot rest putting pressure on her heel. The resident's heels were pressing directly on the wheelchair foot pedals. -At 1:51 p.m. the resident was lying in bed on her back. The heel protector boots were not on the resident's feet and the resident's heels were not offloaded to relieve pressure from the bed's surface on the heels. The heel protectors boots were observed on top of the resident's recliner and not on her feet. On 12/13/23 Resident #54 was observed from 9:28 a.m. to 10:55 a.m. The resident was lying in bed on her back. The resident's feet were not offloaded or floated off the mattress nor was the resident wearing the prescribed heel protector boots. On 12/14/23 at 1:27 p.m. Resident #54 was observed lying in bed. The resident was in bed lying on her left side facing the wall with a pillow between the resident's legs. The resident's heels were not floated nor did the resident have the heel protector boots on her feet. C. Resident representative interview Resident #54's representative was interviewed on 12/14/23 at 1:50 p.m. The resident's representative said she was informed about the development of a pressure wound on the resident's right heel that started as a blister that popped and required specialty care. The resident's representative said she was not aware where the resident's heel protectors were and had not seen the resident wearing the boots during any of her visits with the resident even on days she arrived early around 7:15 a.m. or late in the evening around 8:15 p.m. when she was in bed. D. Wound observation and interview On 12/14/23 at 1:55 p.m. Resident #54's wound care procedure completed by licensed practical nurse (LPN) #3 was observed. The resident was lying in bed and not wearing heel protector boots nor were her heels offloaded prior to the wound care beginning. The resident's right heel wound was observed during the wound dressing change. The resident's right heel wound was observed, it was small and round about the size of a dime. The surface of the wound was pinkish white and the edges of the wound were pink in color. There was no drainage, odor, slough (whitish yellow stringy dead tissue) or other necrotic (dead) tissue on the wound. The resident attempted to pull her right foot from the LPN's hands throughout wound care but did not complain of pain. LPN #3 requested the help of a CNA to hold onto the resident's right foot during the procedure. LPN #3 completed the wound treatment per the physician's orders but did not measure the wound and neither the LPN or CNA made any attempt to apply the resident's protective heel boots or offload the resident's heels when the wound care procedure was complete. LPN #3 was interviewed following the procedure. LPN #3 said the resident developed the right heel wound within weeks of her admission. LPN #3 said the resident wore a pair of shoes that likely caused the blister to the right heel. LPN #3 said after the blister developed the resident's daughter took all the resident's shoes home and returned with socks and slippers. LPN #3 said she knew the resident had heel protectors to wear while in bed but did not know where they were and thought that the resident's daughter may have taken them home to wash them. LPN #3 said she would ask the nurse aide to look for the heel protectors and put them on the resident's feet while the resident was in bed. LPN #3 said the resident would not allow the staff to put a pillow under her lower legs and often kicked the pillow off her bed. D. Record review Review of the December 2023 CPO revealed the following order for the treatment of pressure injuries: -Bilateral transfer bars to bed to assist the resident with bed mobility, repositioning, and transfers. Order date 9/8/23. -Complete weekly skin observation and document. Order date 9/14/23. -Provide a protein house smoothie daily. Order date 9/15/23. -Apply bunny boots to bilateral (both) feet/heels. Order date 9/19/23. -Check the air mattress for proper functions every shift. Order date 9/21/23. -Float (off-load) heels while in bed, off-load wound, pressure offloading boot, order date 9/20/23. -Provide Prostat (nutritional supplement drink) two times per day for impaired skin. Order 10/2/23. Review of the December 2023 CPO revealed the following wound care orders: -Wound care: clean right heel with wound cleanser, apply calcium alginate in the morning every other day. Order start date 9/7/23, discontinued 11/22/23. -Wound care: Apply Leptospermum honey (ointment) to the right heel apply every two days, cover the wound with gauze island border (bandage), every two days for 30 days, float heels, offload wound, pressure offloading boot, order date 11/22/23, discontinued 12/13/23. -Wound care: Apply Alginate calcium dressing to the right heel daily and cover with gauze 4.5 inches once a day, order date 12/13/23. The 9/15/23 Braden Skin Risk assessment (a guide utilized for assistance with predicting pressure ulcer risk) documented Resident #54 was at moderate risk for developing pressure ulcers based on a score of 14 out of 23 (a lower score indicates a higher risk of developing pressure ulcers). The assessment documented the resident had slightly limited sensory perception, her skin was constantly moist, she was chairfast, had slightly limited mobility, her food intake was inadequate, and her potential for friction (the force of rubbing two surfaces against one another) and shear (gravity force pushing down on the resident's body with resistance between the resident and the chair or bed) was a potential problem. The resident had additional risk factors of advanced age and poor cognition. Review of Resident #54's comprehensive care plan, dated 10/12/23, with no revision date, revealed the resident was at risk for skin breakdown related to impaired mobility and had an unstageable right heel wound and was followed by the wound care specialist. Interventions include: Administer supplements as ordered; provide an air mattress; apply creams and ointments as ordered and as needed; provide a bilateral transfer bar to assist with bed mobility; positioning; and transferring as needed. Apply bunny boots in bed as tolerated to protect heels and relieve pressure; check for incontinence and change upon awakening, before and after meals, at bedtime and as needed; complete weekly skin assessments; float heels in bed as tolerated; monitor lab values as ordered; and provide a pressure reduction cushion to wheelchair. Follow physician's orders for wound care treatments; physical therapy and occupational therapy; and refer to dieticians as indicated. Notify the resident physician if skin breakdown occurs for treatment recommendations and orders and implement promptly. Review of Resident #48's medical record revealed the following wound care notes: The 9/16/23 skin/wound nursing note documented: The CNA noticed serous drainage on the resident's bed sheet this morning and called the nurse to the resident's bedside. The resident has a large broken blister on the medial aspect of the right heel, approximately 1.5 inches by 2.0 inches. The wound was cleaned with a wound cleanser and wrapped with Kerlix (a stretch gauze bandage). A call to the doctor was made, no new orders received. The 9/16/23 skin/wound nursing note documented the resident's Blister broke on the medial aspect (middle center) of the right heel, serous drainage present, the wound measured approximately 1.5 inches x 2.0 inches, the resident's skin was moist with a pink wound bed. The wound was cleaned with wound cleanser, a Telfa pad (non-stick bandage) was applied with kerlix wrapped around the resident's right ankle to hold the dressing in place, bunny boots applied. The 9/17/23 skin/wound care nursing note documented The resident's right heel dressing was clean, dry, and intact. The 9/18/23 nursing note documented The resident's heel continues to be monitored. The resident had no complaints of pain and her vital signs were within parameters with no fever. Dressing was clean, dry, and intact. The 9/18/23 long term care note documented: The resident was seen resting in bed. The resident had a blister right heel, no tenderness reported. Continue with Kerlix dressing, referred to the wound care specialist. The 9/20/23 wound physician's note documented the resident had an unstageable deep tissue wound to the right heel measuring 8.0 centimeters (cm) by 4.0 cm by 0.1 cm and a surface area of 36.00 cm2. The wound had moderate serous exudate (clear yellowish fluid), 60% granulation, 40% viable dermis tissue and no slough. Wound care orders were to apply alginate calcium daily for 30 days, gauze 4.5 inches once daily for 23 days, float heels, offload wound, pressure offloading boot. The 9/27/23 wound physician note documented the resident had an unstageable deep tissue injury to the right heel measuring 7.0 cm by 4.0 cm by 0.2 cm and a surface area of 28.00 cm2. The wound had 30% necrotic tissue (dead tissue), 50% granulation tissue (healthy tissue), 10% slough (clear yellowish fluid), and 10% viable dermis tissue. Wound care orders were alginate calcium daily for 30 days, gauze 4.5 inches once daily for 23 days, float heels, offload wound, pressure offloading boot. The 10/2/23 nutrition note documented the resident was on a pureed diet with supplements. The resident's oral intake was erratic while the resident's weight remained stable. The resident had an unstageable deep tissue injury that was improving. The resident required increased nutrition related to impaired skin integrity. The 10/4/23 wound physician notes documented the resident had an unstageable (due to necrosis) full thickness right heel wound measuring at 5.0 cm by 4.5 cm by 0.2 cm and a surface area of 22.50 cm. The wound had light serous drainage, 70% granulation tissue, 20% slough, and 10% eschar (a scab). Improvement of the wound as evidenced decreased necrotic tissue, decreased surface area, increased epithelialization (new skin growth). Wound care orders were alginate calcium daily for 30 days, gauze 4.5 inches once daily for 23 days, float heels, offload wound, pressure offloading boot. The 10/5/23 interdisciplinary team (IDT) note documented The resident has an unstageable wound to the right heel and was seen by the wound care specialist. The resident's wound improved as evidenced by decreased necrotic tissue, decreased surface area, and increased epithelialization. The resident receives supplementation and weight remains stable despite poor to fair oral intake. The 10/11/23 wound physician notes documented the resident had an unstageable (due to necrosis) full thickness right heel wound measuring at 4.0 cm by 4.0 cm by 0.2 cm and a surface area of 16.00 cm2. The wound had moderate serous drainage, 80% granulation tissue, 20% slough, and no eschar. Improvement of the wound as evidenced decreased necrotic tissue, decreased surface area, increased epithelialization. Wound care orders were alginate calcium daily for 30 days, gauze 4.5 inches once daily for 23 days, float heels, offload wound, pressure offloading boot. The 10/12/23 IDT note documented The resident has an unstageable wound to the right heel and was seen by the wound care specialist. The resident's wound improved as evidenced by decreased necrotic tissue, decreased surface area, and increased epithelialization. The resident receives supplementation and weight remains stable despite poor to fair oral intake. The 10/18/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 3 cm by 3 cm by 0.1 cm and a surface area of 9.00 cm2. The wound had moderate serous drainage, 90% granulation tissue, 10% slough, and no eschar. Improvement of the wound as evidenced by decreased surface area and decreased slough. Wound care orders were alginate calcium daily for 30 days, gauze 4.5 inches once daily for 23 days, float heels, offload wound, pressure offloading boot. Surgical excision debridement procedure (removal of necrotic tissue). The 10/25/23 IDT note documented The resident has an unstageable wound to the right heel and was seen by the wound care specialist, last seen by wound care on 10/25/23. The resident's wound improved as evidenced by decreased necrotic tissue, decreased surface area, and increased epithelialization. The resident receives supplementation and weight remains stable despite poor to fair oral intake. The 11/15/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 2.0 cm by 2.0 cm by 0.1 cm and a surface area of 4.00 cm2. The wound had moderate serous drainage, 90% granulation tissue, 10% slough, and no eschar. Improvement of the wound as evidenced by decreased surface area. Wound care orders were alginate calcium daily for 30 days, gauze 4.5 inches once daily for 30 days, float heels, offload wound, pressure offloading boot. The 11/16/23 nutrition note documented the resident had a stage 4 pressure injury to the right heel that was improved per the wound report dated 11/15/23. Will continue with all nutritional interventions and will encourage a high protein diet for wound healing. The 11/22/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 1.5 cm by 1.5 cm by 0.1 cm and a surface area of 2.25 cm2. The wound had light serous drainage, and 100% granulation tissue. Improvement of the wound as evidenced by decreased surface area. Wound care orders were Laptospermum honey apply every two days for 30 days, gauze island border apply every two days for 30 days float heels, offload wound, pressure offloading boot. The 11/29/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 1.5 cm by 1.0 cm by 0.1 cm and a surface area of 1.50 cm2. The wound had light serous drainage, 80% granulation tissue, and 20% slough. Improvement of the wound as evidenced by decreased surface area. Wound care orders were to apply Leptospermum honey every two days for 23 days, gauze island border apply every two days for 23 days float heels, offload wound, pressure offloading boot. The 12/6/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 1.1 cm by 1.0 cm by 0.1 cm and a surface area of 1.10 cm2. The wound had light serous drainage, 90% granulation tissue, and 20% slough. Improvement of the wound as evidenced by decreased surface area and decreased slough. Wound care orders were to apply Leptospermum honey every two days for 16 days, gauze island border apply every two days for 16 days float heels, off load wound, pressure off loading boot. The 12/13/23 wound physician notes documented the resident had a stage 4 full thickness pressure wound on the right heel measuring at 1.1 cm by 1.0 cm by 0.1 cm and a surface area of 1.10 cm2. The wound had moderate serous drainage, 90% granulation tissue, and 10% slough. Improvement of the wound was documented as not at goal. Wound care orders were to apply alginate calcium daily for 30 days, gauze 4.5 inches daily for 30 days, float heels, offload wound, pressure offloading boot. The 12/14/23 nurses note documented Wound care was completed to the resident's right heel. The wound was dry with no slough, measures about the size of nickel- circular edges were dry, no erythema noted around the heel, no erythema in the wound itself-covered with alginate cream, wrapped in kerlix. E. Staff interviews CNA #4 was interviewed on 12/13/23 at 9:25 a.m. CNA #4 said Resident #54 was able to turn from side to side on her own but favored the left side and preferred to lay on her back. CNA #4 said the resident often refused to get out of bed and often refused care. CNA #4 said the resident had heel protectors in her room but did not know where they were and said she would look for them or ask the resident's daughter if she took them home to wash. CNA #4 said when she arrived at 6:00 a.m. the resident did not have heel protectors on her feet and understood from the night CNA, the resident did not like the heel protectors and kicked them off her feet and onto the floor. CNA #4 said she knew the resident developed a pressure wound but did not know where the wound was located. LPN #2 was interviewed on 12/14/23 at 1:55 p.m. LPN #2 said she had treated the resident's wound a few times but not recently. LPN #2 said the resident's wound on her right heel was improving but recognized the resident's risk for additional wounds due to her thin skin. LPN #2 said the resident's heel protectors were in the drawer in the resident's room but did not place the heel protectors on the resident. The DON was interviewed on 12/14/23 at 3:00 p.m. The DON said facility leadership tried to schedule the same CNAs and nurses with residents to ensure continuity of care. The DON said ensuring consistent assignments allowed familiarity with the care plan and interventions associated with wound care treatment, wound assessments and improved wound healing. The DON said high risk residents with skin integrity issues require extraordinary measures, including, heel protection and specialized mattresses. The DON said she understood the Resident #54's right heel wound was improving but she was unaware that the resident's heel protectors were missing and had not been on the resident's feet for the last three days, IV. Resident #48 A. Resident status Resident #48, age greater than 60, was admitted on [DATE]. According to the December 2023 CPO, diagnoses included major depressive disorder, anxiety, septic (infection) of the right hip and acute respiratory failure. The 9/22/23 MDS assessment revealed that the resident had intact cognition with a BIMS score of 13 out of 15. The resident was independent with bed mobility, dressing, transfers, toilet use, and personal hygiene and required supervision/touch assistance with bathing/showering. The resident had one stage 1 pressure injury or scar over a bony prominence; was at risk of developing pressure injuries and had no unhealed pressure wounds. The resident had one venous/arterial ulcer. The resident was receiving skin and ulcer treatment including pressure reducing device for the chair and bed and application of wound dressing/bandages and application of ointment /medications to areas other than to the feet. B. Resident observations and interview On 12/11/23 at 10:05 a.m. Resident #48 was sitting in a wheelchair in his room with his left foot resting atop the left foot pedal on his wheelchair. The resident was not wearing the prescribed bunny boots but instead was wearing slippers that offered little cushioning for his heel as it rested on the footrest of his wheelchair. At 1:00 p.m. Resident #48 was dozing in bed on his back with his heels resting directly on the surface of the mattress. The resident was wearing regular socks on his feet; his heels were not floated or offloaded off the mattress or covered by bunny boot heel protectors. The resident was wearing white socks on his feet, the left sock was bulky at the heel with what appeared to be a dressing underneath. On 12/12/23 at 1:47 p.m. the resident was sitting upright in a wheelchair. The wheelchair had a two to three inch black cushion on the seat. The resident was wearing white socks and slippers on his feet offering little cushioning for the pressure of his heels on the wheelchair's footrests. The resident was not wearing the prescribed bunny boots. Both of the resident's feet were pressed against the footrests on the wheelchair as the resident was leaning forward reading a book. On 12/13/23 at 3:45 p.m. the resident had white socks and black slippers on his feet. The resident's feet were positioned flat atop the floor. The foot pedals to the resident's wheelchair were removed and located at the head of his bed on the floor. There were no signs of heel protectors in the resident's room. On 12/14/23 at 11:40 a.m. the resident was eating lunch and leaning forward in his wheelchair with both feet planted directly on the floor. The resident was not wearing slippers or shoes but his feet were covered with black socks. There were no heel protectors on site. The resident was interviewed on 12/13/23 at 11:58 a.m. The resident said he had an open sore on the left heel and saw the wound care doctor this morning. The resident said the nursing staff were changing the dressing on his left heel daily. The resident said he had no idea what happened to his heel protector boots. C. Wound observation and interview On 12/12/23 at 12:00 p.m. Resident #48's stage 2 left heel wound was observed during the wound dressing change performed by LPN #3. Resident #48 was lying in bed on his back with his left foot[TRUNCATED]

Based on interviews and record reviews, the facility failed to provide and deploy sufficient nursing staffing during weekends to meet the needs of residents in keeping with their comprehensive care plans and ensure their highest practicable quality of care. Specifically, the facility failed to provide sufficient nursing staff fiscal year (FY) Quarter 3 2023 (April 1-June 30) with excessively low weekend staffing to provide dignified and quality care, prevent falls and accidents, and prevent pressure ulcers. Cross-reference F686: failure to prevent pressure ulcer; and F689 failure to prevent falls and accidents. Findings include: I. Facility policy On 12/13/23 at 3:12 p.m., the facility's staffing policy was requested from the nursing home administrator (NHA). However, it was not provided by the end of survey 12/14/23. II. Resident status According to the staffing data report checked on 12/7/23 for quarter 3 (4/1/23 to 6/30/23), the facility failed to provide sufficient nursing staff during weekend shifts. The census and conditions for December 2023 reported 82 total resident population from the facility's three units. -The rehabilitation unit consisted of 31 residents who required one to two staff assistance with ambulation due to limited range of motion (LROM); -56 of the 82 residents required one to two staff members to assist with toileting. III. Staffing requirements The staff coordinator (SC) was interviewed on 12/14/2 at 12:10 p.m. She said the goals for staffing for the three units were two to three certified nurse aides (CNAs) for each unit depending on the facility's census and two nurses for the three units. The SC said the facility had flexible scheduling from 6:00 a.m. to 6:00 p.m., 6:00 a.m. to 2:00 p.m., and 2:00 p.m. to 10:00 p.m. to meet the needs of the nursing staff and the units. The SC said the crisis levels had been weekends and night callouts. She said the facility had recently hired a weekend nursing supervisor to handle unplanned call-offs. The SC said the facility used to utilize agency staff, however, the facility did not have any nursing vacancies therefore they have stopped using agency staff. IV. Resident interviews Resident #76 was interviewed on 12/11/23 at 2:31 p.m. He said he received a laxative on 11/27/23 and had the urgency to use the bathroom, however, the nursing staff failed to respond to his call light. The resident waited over half an hour and then attempted to help himself to the bathroom resulting in a fall with injuries to his forehead and right knee, with increased pain to his casted and broken left leg. The resident reported extreme pain and discomfort and was afraid to leave his room due to the fear of falling again. Resident #67 was interviewed on 12/11/23 at 4:47 p.m. and said call light response could take up to half an hour depending on the time of the day. The resident said he had slid out of his wheelchair twice trying to reach out to grab something due to the staff not answering the call light promptly. A group of six alert and oriented residents (Residents #23, #24, #39, #51, #58, and #68) selected by the facity were interviewed on 12/12/23 at 3:19 p.m. The resident group said the facility neede to hire more staff due to staff shortages particularly on the weeeksnds and in the mroning There group members said were several occasions when each of the residents inthe group had to wait for staff to be avaialb to receive needed care. The residents said sometimes it takes over half an hour for staff to answer their call light. One reisdne said hey had to wait for a long time to get help to use the bathroom which was uncomfortable. V. Staff interviews CNA #2 was interviewed on 12/13/23 at 1:40 p.m. The CNA said she worked the day shift and it was difficult to provide timely care to all residents and answer the call lights timely when there were only a few CNAs. She stated when there were only two CNAs on the night shift, the morning shift could be chaotic because the night shift staff could not get to everything which could affect the day shift as well. Registered nurse (RN) #5, was interviewed on 12/14/23 at 12:45 p.m. The RN said she usually worked on the weekend, and believed there were shortages of nursing staff everywhere and did her best with what was available to meet the needs of the residents. She said she usually works with two nurses and two to three CNAs depending on the facility census. She said since the facility hired a weekend nurse supervisor staffing on the night shift had been better. The nursing home administrator (NHA) and the director of nursing (DON) were interviewed on 12/14/23 at 4:50 p.m. The DON said the facility tried to reach its ideal staffing levels. She said staffing was based on acuity and the unit census. She said the facility tried to keep staffing during the day and evening to 1:12 ratio of staff to residents but it was not always possible. The NHA said the facility had experienced nursing staff challenges in the past however the facility had utilized job fairs, employee sign-on bonuses, and reimbursement for obtaining nursing licenses. She said these had enabled the facility to fill all its nursing vacancies. The NHA said the facility no longer utilizes agency staff. The NHA said call off was an issue for the night shift but it had improved since the facility hired a weekend nursing supervisor. The NHA said she did not know the reason the facility reported excessively low weekend staffing.

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 three out of three units at the facility. Specifically, the facility failed to: -Ensure proper infection control practices were followed in the laundry area including wearing a gown when loading dirty laundry into the washing machines, and storing dirty laundry away from clean areas and clean clothing ; and -Ensure residents were provided an opportunity to participate in hand hygiene before meals. Findings include: On 12/11/23 the facility was currently in COVID-19 outbreak status. I. Failure to ensure proper infection control practices were followed in the laundry area A. Professional reference The Centers for Disease Control (CDC) Linen and laundry management, retrieved online from https://www.cdc.gov/hai/prevent/resource-limited/laundry.html, on 12/19/23, read in pertinent part: Always launder soiled linens from patient care areas in a designated area, which should: -Be a dedicated space for performing the laundering of soiled linen -Not contain any food, beverage or personal items -Have floors and walls made of durable materials that can withstand the exposures of the area (e.g., large quantities of water and steam) -Have a separation between the soiled linen and clean linen storage areas, and ideally should be at negative pressure relative to other areas -Always wear reusable rubber gloves before handling soiled linen (e.g., bed sheets, towels, curtains) -Reprocess (clean and disinfect) the designated container for soiled linen after each use -Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (eat least once daily) cleaned with a neutral detergent and warm water solution. B. Facility policy The Departmental (Environmental Services)-Laundry and Linen policy and procedure, revised January 2014, was provided by the nursing home administrator (NHA) on 12/14/23 at 7:20 a.m. It read in pertinent part, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. Standard precautions: separate soiled and clean linen at all times, wash hands after handling soiled linen and before handling clean linen, and consider all soiled linen to be potentially infectious and handle with standard precautions. Sorting soiled linen: employees sorting or washing linen must wear a gown and gloves. A mask may be worn if aerosolization is expected. Use heavy-duty rubber gloves for sorting laundry. Washing linen and other soiled items: Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. C. Observations and interviews On 12/13/23 at 9:42 a.m. The facility laundry room area was toured with the plant operations director (POD). There were two large red dirty laundry bins containing soiled dirt laundry in the clean laundry area. The dirty laundry was not covered and none of the laundry was in bags. The laundry aide (LA) said he had sorted the dirty clothing earlier in the day. The POD said the dirty laundry should not be on the clean side of the laundry room because of the risk of cross contamination where germs could spread to the clean laundry and then throughout the facility when the clean clothing and linens were delivered to the resident units. There was an additional observation of a yellow colored laundry tub/container that was dirty with dried red and brown stains that had dripped down the sides of the container. The POD said he had no documentation that the facility was doing any regular cleaning of the laundry containers. The POD said the yellow containers were for laundry from the kitchen. The director of nursing (DON)/infection control preventionist (IP) was interviewed on 12/13/23 at 10:30 a.m. The DON said she had her IP certification. The DON toured the laundry room area and observed the two red tubs of dirty laundry that had been stored on the clean side of the laundry room. The DON said this was an infection control problem. The DON observed the dirty yellow laundry tub and that there was no laundry container/tub cleaning schedule. The DON observed the laundry room's dirty side and said it was too small to store the two large red dirty bins and there was also no room to bring in a clean laundry bin to the clean laundry room side after the linens were washed so they could be sorted and folded on the clean side. The DON observed LA putting dirty laundry into the washing machine he was wearing disposable vinyl gloves and no gown. The DON said he should be wearing heavy-duty rubber gloves and a gown to protect himself from infection and prevent the spread of infectious disease to the clean laundry when processing the laundry after it was washed. The assistant director of nursing (ADON)/IP was interviewed on 12/13/23 at 2:43 p.m. The ADON/IP said he also worked as an IP in the facility and had IP certification. He said dirty laundry should not be kept in the clean laundry section because it was a source of infection. He said it was important to process the laundry correctly because it was going to the residents for personal use. He said the LA should wear gloves and a gown to protect and prevent cross contamination when touching the dirty laundry and then handling the clean laundry and linens. II. Failure to ensure residents were provided with an opportunity to participate in hand hygiene before meals A. Facility policy The Handwashing/Hand Hygiene policy and procedure, undated, was provided by the NHA on 12/14/23 at 7:20 a.m. It read in pertinent part, The facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Residents, family members and /or visitors will be encouraged to practice hand hygiene. B. Observations On 12/11/23 at 9:01 a.m., breakfast was observed. Residents in the large long-term care (LTC) dining room were arriving and getting ready to eat breakfast. Staff members had not offered or provided the resident any type of hand hygiene including the use of alcohol-based hand rub to cleanse their hands prior to eating the meal. The residents had toast for breakfast; the residents picked up their toast and ate with their hands. On 12/11/23 at 11:35 a.m. Residents were not offered or provided a mechanism to wipe/sanitize their hands before the lunch meal in the LTC dining room. On 12/11/23 at 11:48 a.m., lunch was observed. Staff started serving lunch after they provided beverages of choice for the residents. Six residents in the rehab dining room arrived in their wheelchairs by self-propelling themselves into the room while touching the wheels of their chairs that rolled directly across the floor to mobilize into the dining room. No hand hygiene was offered or provided before or after lunch. On 12/11/23 at 11:52 a.m., lunch was observed. The rehabilitation dining room was observed, no hand hygiene was offered or provided to the residents who were waiting for their meals to arrive. On 12/13/23 at 12:10 p.m., lunch was observed. Three residents self-propelled themselves to the dining room in a wheelchair, by handling the wheels rolling across the floor. The residents had a roll on their tray; the residents picked up the diner roll and ate with their fingers. None of the residents were offered any form of hand hygiene to any residents in the dining room prior to the residents eating their meals. C. Resident interviews Resident #66 was interviewed on 12/14/23 at 10:35 a.m. Resident #66 said the staff had not offered or encouraged hand hygiene for herself or other residents. She said she was fortunate to be able to get to her sink in her wheelchair to perform hand hygiene before meals herself. Resident #62 was interviewed on 12/14/23 at 10:39 a.m. Resident #62 said the staff had not offered or encouraged hand hygiene with him before meals and he was dependent on their care. Resident #182 was interviewed on 12/14/23 at 10:52 a.m. Resident #182 said the staff had not offered or encouraged hand hygiene with her before meals. D. Staff interviews The ADON and DON were interviewed on 12/13/23 at 2:43 p.m. The ADON said he recommended hand hygiene for all residents before meals and after using the restroom. He said staff should offer residents soap and water or alcohol-based hand sanitizer to perform hand hygiene. He said the staff should be offering hand hygiene to residents, to stop the source of infections at the starting point.

Based on observations and interviews, the facility failed to label and date stored food items and distribute and serve food in a sanitary manner in two of three kitchens. Specifically, the facility failed to: -Ensure cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; -Ensure that stacked pans did not contain moisture between the pans; and, -Ensure kitchen vents in the main kitchen were free from hanging dust. Findings include: I. Cold food temperatures A. Professional reference According to The Food and Drug Administration (FDA) Food Code (2019) p. 441, retrieved on line on 12/20/23 from https://www.fda.gov/media/164194/download?attachment When food is held, cooled, and reheated in a food establishment, there is an increased risk from contamination caused by personnel, equipment, procedures, or other factors. If food is held at improper temperatures for enough time, pathogens have the opportunity to multiply to dangerous numbers. Proper reheating provides a major degree of assurance that pathogens will be eliminated. It is especially effective in reducing the numbers of Clostridium perfringens (C. perfringens) that may grow in meat, poultry, or gravy if these products were improperly cooled. Vegetative cells of C. perfringens could cause foodborne illness when they grow to high numbers. Highly resistant C. perfringens spores will survive cooking and hot holding. If food is abused by being held at improper holding temperatures or improperly cooled, spores could germinate to become rapidly multiplying vegetative cells. B. Facility policy The food and nutrition service policy was received on 12/13/23 at 2:00 p.m. from the nursing home administrator (NHA). The policy read in pertinent part, The food and nutrition service employees will prepare, distribute and serve food in a manner that complies with safe food handling practices. The policy interpretation and implementation included, The danger zone for food temperatures above 41 degrees Fahrenheit (F) and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Proper hot and cold temperatures are maintained during food distribution and services. Foods which were held in the temperature danger zone are discarded C. Observations The lunch meal in the first-floor kitchen was observed on 12/13/23 from 11:20 a.m. to 1:30 p.m. -At 11:24 a.m. the Dietary aide (DA) #1 transported the lunch meal from the second-floor main kitchen to the satellite kitchen on the first floor and started setting up the resident meals. DA #1 placed two bowls of chef salad on the counter. The salad was not on ice to keep it cold. The chef's salad included eggs, lettuce, cheese and tomatoes. -At 11:30 a.m., DA #1 took the food temperatures of the tray line, however, did not temp the cold foods inlcuign the salads. The two chef salads continued to sit on the counter without being placed on ice or refrigerated. -At 1:30 p.m. a certified nurse aide (CNA) #2 presented a lunch card for a resident. The DA picked up one of the chef salads and gave it to the CNA to be served to the resident without obtaining a temperature. The CNA asked the DA to take the temperature of the salad before she would serve it to the resident. The DA #1 obtained the temperatures of both chef salads. The temperature of the first chef salad was 69 degrees F and the second bowl was 59.6 degrees F. The CNA requested a fresh salad bowl for the resident. D. Interviews The chef (C) #2 was interviewed on 12/13/23 at 1:55 p.m. The Chef said the temperature of cold foods including salads should be below 41 degrees F. The chef said to maintain the appropriate temperatures, the DA should have placed the salads in the kitchen refrigerator or on ice until ready to be served to prevent harmful pathogens from growing on the food which could cause a resident to be ill. II. Moisture on pans A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on line on 12/20/23 form https://drive.google.com/file/d/1XuYydJAC9ZhC1Be6jxIAct0FVbuXuIi5/view , read in pertinent part; Unless used immediately after sanitization, all equipment and utensils shall be air-dried. Towel drying shall not be permitted. Clean equipment and utensils shall be stored in a self-draining position that allows air drying. B. Observations On 12/11/23 at 9:30 a.m., moisture was observed between pans stacked four high for quarter-size pans, eight high for quarter-size pans and four high for eighth-size pans. On 12/12/23 at 2:01 p.m. observations were conducted with the chief executive chef (CEC); moisture was observed between pans stacked six high for quarter-size pans and four high for eighth-size pans. C. Staff interviews The CEC was interviewed on 12/12/23 2:02 p.m. The CEC said the pans should not have moisture between them and should be air-dried to ensure bacteria did not grow. He separated the pans from being stacked together to be air-dried. III. Kitchen and food service area A. Professional reference According to The Food and Drug Administration (FDA) Food Code (2019) p. 441, retrieved on line on 12/20/23 from https://www.fda.gov/media/164194/download?attachment Surface Characteristics. Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible. -Heating and air conditioning system vents that are not properly designed and located may be difficult to clean and result in the contamination of food, food preparation surfaces, equipment, or utensils by dust or other accumulated soil from the exhaust vents. B. Facility policy and procedures The Sanitation policy, last revised in November 2022, was provided by the NHA on 12/13/23 at 4:01 p.m. It read in pertinent part, The food service area is maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. C. Observations On 11/11/23 at 9:30 a.m. the initial kitchen tour was conducted and the following was observed: -Beside the ice machine and the south wall of the main kitchen was a thick dark gray dust from the side of the ice machine. The wall beside the ice machine was covered with dirt, dust and large particles of white-colored debris. -The hanging light fixtures over the food prep areas were covered with blackish gray dust on the top of the fixtures and along the chains that connected the light fixture to the ceiling. The above observation remained through the survey period from 12/11/23 to 12/14/23. D. Staff interview The CEC was interviewed on 12/13/23 at 2:00 p.m. The CEC said there was a daily and quarterly deep cleaning schedule for maintaining the kitchen in a sanitary condition. The CEC acknowledged the hanging dust around the vents, on the light fixtures and on the ice machine could be problematic and was not sanitary. The CEC said the hanging dust would be removed as soon as possible. The CEC acknowledged the area around the ice machine needed attention and will ensure the proper cleaning was completed. The NHA was interviewed on 12/14/23 at 4:50 p.m. The NHA said she was informed by the CEC about those identified concerns at the kitchen. The NHA said she would make sure the kitchen staff were educated on proper kitchen sanitation.

Based on record review, observations, and interviews, the facility failed to keep residents safe from accident hazards related to falls for one (#76) of two residents reviewed for falls out of 33 sample residents. Specifically the facility failed to provide Resident #76 timely assistance to use the bathroom after the administration of a laxative medication causing the resident to fall and become injured sustaining an abrasion to the head and knee pain. Findings include: I. Resident #76 A. Resident status Resident #76, under age 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included pain, difficulty in walking, abnormal posture, muscle weakness, anxiety disorder, depression, and fracture of the upper and lower end of left fibula with subsequent encounter for closed fracture. The 11/24/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for a mental status (BIMS) score of 12 out of 15. The resident requires moderate assistance from staff with toileting. He requires supervision for personal hygiene, moderate assistance with bed mobility, set-up help with eating, and moderate assistance with mobility. The resident had no behaviors. The MDS documented the resident had a fall incident in the last month prior to admission. B. Resident observation and interviews On 12/11/23 at 10:13 a.m. the resident was observed lying in his bed on his back watching television. The resident's left leg was in a cast from the left knee down to his ankle. Resident #76 said the cast was from a previous fall incident that occurred at home prior to his admission to the facility. The resident said he was admitted to the facility to heal from the fall. On 12/12/23 at 10:30 a.m. the resident was interviewed. The resident said he did not leave his room because he was afraid that he would fall. The resident said he recently had a terrible fall in the facility after trying to take himself to the bathroom. The resident said he was given a laxative earlier the day of the fall, on 11/27/23, and after a while it took effect and he needed to use the toilet urgently. The resident said he turned his call light device on and waited over a half an hour but did not get any response. The resident said he could no longer wait for staff so he tried taking himself to the bathroom even though he was not supposed to be putting weight on his casted leg and fell . The resident said he was injured in the process. Resident #76 said when he fell he fell straight on his face and sustained a bump on his forehead and scraped his right knee. The resident said he was in a lot of pain, especially in his left casted leg. C. Record review According to the resident's comprehensive care plan initiated on 11/27/23, the resident had a history of falls and was at risk for falls due to limited range of motion to the lower extremities; tremors; medication use; weakness; and unsteady balance. Care plan interventions before the resident's fall incident on 11/28/23 included: ensuring the call device was within the resident's reach at all times and encouraging the resident to use it for assistance. Nursing staff were to ensure the resident's bed was kept in a low position, provide frequent checks, and assist the resident with his toileting needs. A skilled nursing note dated 11/22/23 documented: On 11/29/23 at 7:26 p.m. the resident fell and had injuries including an abrasion with no other injuries being documented. -However, the resident said he had sustained a bump on his forehead (see resident interview above). The post fall investigation report dated 11/28/23 documented: On 11/28/23 at 12:50 p.m. the cause of the resident's fall occurring on 11/27/23 was a result of a bowel urgency after the resident was given a laxative. The interdisciplinary team (IDT) recommended post-fall interventions including keeping the resident's bed in a lowest position, offering frequent checks to meet the resident's care needs, and providing the resident assistance with toileting needs when laxatives were given. D. Staff interviews Certified nurse aide (CNA) #3 was interviewed on 12/14/23 at 11:30 a.m. The CNA said the resident was able to use his call light when he required assistance with care. The CNA said she did remember the resident's fall that occurred on 11/27/23 and was not aware the resident received a laxative on the day of the fall. She said for the safety of the residents it was important for the nursing staff to communicate effectively to prevent such incidents. Licensed practical nurse (LPN) #2 was interviewed on 12/14/23 at 11:40 a.m. LPN #2 said it was important to offer frequent checks on residents who required assistance to use the bathroom. The LPN said after administering laxatives to residents, it was important to regularly check on the resident to ensure the effectiveness of the medication and offer assistance to use the bathroom. The director of nursing (DON) was interviewed on 12/14/23 at 2:20 p.m. The DON said nursing staff were supposed to provide frequent checks on residents when they administer laxatives to residents not only for the effectiveness of the laxatives but also for the resident's safety. The DON said the resident's care plan was updated on 11/28/23 to include frequent checks when the resident receives laxatives. The DON said the fall incident could have been prevented if staff responded promptly to the resident's call light. The DON said the facility would provide education to the nursing staff to offer frequent checks on all residents who receive laxatives.

Based on resident observations, record review, and staff interviews, the facility failed to ensure residents received respiratory treatment as ordered for one (#185) of two residents reviewed for supplemental oxygen use out of 33 sample residents. Specifically, the facility failed to: -Administer oxygen therapy according to the physician's order for Resident #185; -Clean and store Resident #185's nebulizer equipment according to the manufacturer's recommendations after each use; and, -Ensure a care plan focus was in place to include Resident#185's respiratory needs and all required components of oxygen therapy, nebulizer treatment, equipment maintenance, and machine storage. Findings include: I. Professional reference According to the World Health Organization Care, cleaning, disinfection and sterilization of respiratory devices retrieved 12/20/23 online from: https://www.who.int/docs/default-source/coronaviruse/care-cleaning-disinfection-and-sterilization.pdf?sfvrsn=c2b0d672_7&download=true Cleaning, disinfection and sterilization are the backbone of infection prevention and control in hospitals and or other health care facilities. All persons who are responsible for handling and reprocessing contaminated elements must: Receive adequate training and periodic retraining. Use appropriate personal protective equipment According to Healthline.com daily cleaning and storage of nebulizers retrieved 12/20/23 online from https://www.healthline.com/health/asthma-nebulizer-machine#cleaning-and-storage. Take off the mouthpiece/mask and remove the medication container. Wash these parts with hot water and a mild liquid dish soap, and shake off the extra water. Let these pieces dry on a clean piece of paper towel or dish towel. Once the parts have dried, store them in an airtight plastic container or bag. Keep in a cool dry area and make sure to keep the nebulizer free of dust. II. Facility policy The Oxygen Administration policy, revised October 2023, was provided on 12/13/23 at 10:00 a.m. by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure was to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician's orders or the facility protocol for oxygen administration. Review the resident's care plan to assess any special needs of the resident. III. Resident #185 A. Resident status Resident #185, over age 65, was admitted on [DATE]. According to the December 2023 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), hypokalemia (a condition of low blood level in potassium), muscle weakness, and dependence on supplemental oxygen. According to the 12/4/23 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required moderate assistance for bed mobility, grooming, and toileting. The resident received oxygen therapy and did not exhibit any behaviors. B. Resident observation and interview The resident's nebulizer was observed on 12/11/23 at 10:10 a.m. The resident was in bed receiving oxygen therapy through an oxygen concentrator by a nasal cannula through the resident's nostrils (nose openings). The oxygen concentrator was set to deliver oxygen to the resident at 5 liters per minute (LPM). The resident's nebulizer, nebulizer tubing and face mask were on the floor by the resident's bed. The nebulizer mask was attached to the tubing and lying directly on top of the armrest of a couch close to the resident's bed. The nebulizer mask was open to air with no protective covering to prevent possible cross contamination of infectious matter. The mask and tubing were soiled with a clouded layer on the surface and inside of the mask. On 12/12/23 at 1:14 p.m., the resident had family members in her room visiting. A visitor sat on the couch moving the nebulizer mask and tubing, sticking the equipment behind the couch in order to lean on the armrest of the couch. The mask remained hanging over the back of the couch throughout the afternoon; and was not cleaned or placed in any type of protective container. The resident had her oxygen on with the nasal cannula in her nostril and the concentrator set to 5 LPM. Resident #185 was interviewed on 12/13/23 at 9:00 a.m. The resident said she use the nebulizer machine (mask and tubing) for her breathing treatment. She said a nebulizer breathing treatment was provided to her last on 12/10/23 when she had difficulty breathing and the maks and tubing had remained on the couch ever since. The resident said she did not recall how many liters of oxygen she was using, the nurse took care of setting the oxygen liter flow. The resident said she was recently diagnosed with pneumonia and had not been feeling great the oxygen and breathing treatments helped her. Resident #185 said the nebulizer machine usually sits on the floor with the mask and tubing on the couch until she needs a treatment. She said she had not noticed the staff cleaning her nebulizer machine after she received a breathing treatment. C. Record review The resident's medical record was reviewed on 12/13/23. The resident had a physician's order for the use of oxygen therapy. The physician's order was for the resident to receive continuous oxygenation at 3 LPM with no additional titration order. -However, the resident's oxygen was observed on two occasions to be set at 5 LPM (see above observations). The December CPO included an order dated 12/10/23 for the use of albuterol via nebulizer inhalation of 3 ml (milliliters) orally via nebulizer every 6 hours, as needed, for COPD. The resident's comprehensive care plan last revised on 12/1/23 documented that the resident was at risk for complications due to a compromised respiratory system related to COPD and cardiovascular disease. -The respiratory care plan focus and interventions included administering oxygen as ordered by the physician, but did not include the required detailed information for respiratory therapy including the type of oxygen delivery system; when to administer oxygen therapy; a list of equipment, equipment maintenance needs, and equipment settings; and treatment needs such as the need for ongoing monitoring of the resident's respiratory status and response to oxygen and other respiratory therapy. -The care plan had no mention of the nebulizer treatment or the machine cleaning instructions. The December medication administration and treatment record (MAR and TAR) documented oxygen at 3 LPM. There was no mention of the nebulizer treatment with the albuterol on the MAR and TAR. IV. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 12/13/23 at 9:45 a.m. CNA #2 said the resident had an order to receive oxygen at 3 LPM. The CNA confirmed that the resident was currently receiving 5 LPM of oxygen. The CNA said she believed all nursing staff was responsible for the care and maintenance of the nebulizer machine. The CNA #2 said the nebulizer should not be sitting on the floor. The CNA said the nebulizer mask needed to be changed and the nebulizer machine disinfected since it had been sitting on the floor for a few days. Licensed practical nurse (LPN) #4 was interviewed on 12/13/23 at 9:50 a.m. LPN #4 said Resident #185 had an order for continuous oxygen at 3 LPM. She said oxygen was considered a medication and needed to be administered according to the physician's order. The LPN confirmed the resident was receiving 5 LPM of oxygen. Upon verification from the resident medical chart, the LPN said the physician's order had not been changed. The LPN corrected the settings of the concentrator to 3 LPM and checked the resident's oxygen saturation rate; it was assessed to be 97 percent. The LPN confirmed that administering the resident's oxygen at 5 LPM was not following the physician's order to administer oxygen and could result in respiratory complications. The LPN said the nebulizer machine should not be sitting on the floor and the mask with the tubing should be properly cared for with a protective cover. The LPN said she would replace the mask and tubing. She said the mask should be stored in a plastic bag when not in use. The director of nursing was interviewed on 12/14/23 at 2:25 p.m. The DON said a physician's order was required for the use of oxygen therapy. She said the care plan should identify how to clean and store a nebulizer machine. The DON said it was important for the nursing staff to follow and maintain the physician's order for the use of oxygen for all residents. The DON said not abiding by the physician's order could cause serious respiratory complications for the residents. The DON said the nebulizer machine and mask should be stored properly by having a stand for the nebulizer machine and a protective cover for the mask and tubing. The DON said lack of proper care for the nebulizer and mask could cause serious respiratory illness for the residents.

Based on observations, record review and staff interviews, the facility failed to ensure it was free of medication error rates of five percent or less. Specifically, the medication pass observation error rate was 7.41% or two errors out of 27 opportunities for error. Findings include: I. Manufacturer guidelines According to Novo Nordisk, Novolog Flexpen https://www.novolog.com/type-2-diabetes/just-heard-about-novolog-t2/novolog/using-flexpen.html it read in pertinent part, Small amounts of air may collect in the cartridge during normal use. To avoid injecting air and ensure proper dosing: Turn the dose selector to 2 units. Hold your (insulin pen) with the needle pointing up, and tap the cartridge gently a few times, which moves the air bubbles to the top. Press the push-button all the way in until the dose selector is back to 0. A drop of insulin should appear at the tip of the needle. If no drop appears, change the needle and repeat. If you still do not see a drop of insulin after 6 tries, do not use the (insulin pen) and contact (manufacturer). A small air bubble may remain at the needle tip, but it will not be injected According to Lantus SoloStar https://www.lantus.com/how-to-use/how-to-inject#solostar-pen it read in pertinent part: Perform safety check Dial a test dose of two units Hold the pen with the needle pointing up and lightly tap the insulin reservoir so the air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that the insulin comes out of the needle. The dial will automatically go back to zero after you perform the test. If no insulin comes out, repeat the safety check two more times. If there is still no insulin coming out, use a new needle and do the safety check again. Always perform the safety test before each injection, never use the pen if no insulin comes out after using a second needle. II. Facility policy and procedure The Medication Administration and Management policy and procedure, revised June 2019, provided by the director of nursing (DON) on 12/14/23 at 7:20 a.m. read in pertinent part: The facility's director of nursing will have an active role in the oversight of medication management. The authorized staff member administers subcutaneous, intramuscular, and intradermal medications. Follow manufacturer's guidelines for medication pen-style delivery for priming and air shots. Insulin pens containing multiple doses of insulin are meant for single residents only, and must never be used for more than one person, even when the needle is changed. Insulin pens must be clearly labeled with the resident's name or other identifiers to verify that the correct pen is used on the correct resident. III. Medication errors Registered nurse (RN) #1 was observed preparing and administering medication to Resident #64 on 12/13/23 at 8:50 a.m. The resident's order was for Novolog (Aspart) 100 units/milliliter FlexPen Subcutaneous Solution Pen-Injector three times daily using a sliding scale. The order was written 11/28/23. The RN obtained the Novolog (Aspart) 100 units/milliliter FlexPen Subcutaneous Solution Pen-Injector from the medication cart. The RN turned the dose knob and dial in the six units. -The RN did not prime the insulin pen before the medication was administered. RN #1 preparing and administering medications to Resident #64. The order was Lantus (Glargine) SoloStar subcutaneous solution (Glargine)100 units/milliliter. Inject 10 units daily subcutaneous in the morning between 7:00 a.m. to 10:00 a.m. for diabetes mellitus. The order was written 10/25/23. RN #1 obtained the Lantus Subcutaneous solution SoloStar 100 Units/milliliters (Insulin Glargine) from the medication cart. RN #1 proceeded to dial in 10 units. -The RN did not complete a safety check (prime) before the insulin was administered per the manufacturer's instructions. IV. Staff Interviews Registered nurse (RN) #1 was interviewed on 12/13/23 at 10:00 a.m. RN #1 said he was not aware of the manufacturer's instructions for either insulin pen. RN #1 said he did not recall whether or not he had training related to insulin pen use. RN #1 said he would make sure to review the manufacturer instructions for both the Novolog FlexPen and the Lantus (Glargine) SoloStar insulin pen immediately and inform nursing leadership of the error. RN #1 said he understood the importance of priming and safety checks before insulin administration to avoid injecting air into subcutaneous tissue. Licensed practical nurse (LPN) #2 was interviewed on 12/13/23 at 10:45 a.m. LPN #2 said she received education on the use of insulin pens but could not remember exactly when she attended the education at the facility. LPN #2 said insulin education was likely completed on hire. LPN #2 said she could use a refresher course because she had not administered insulin via an insulin pen for a long time. LPN #2 said she was not provided the manufacturer's instructions for delivery of insulin via an insulin pen and asked where she could find them. LPN #3 was interviewed on 12/13/23 at 11:10 a.m. LPN #3 described the process for using an insulin pen but did not include the step to prime the pen nor complete a safety check prior to administration. LPN #3 said she did not receive training on how to use insulin pens when she started working at the facility. LPN #3 said she had never read the manufacturer's instructions to prime or complete a safety check with either insulin pen. LPN #3 said she would look up the manufacturer's instructions for both insulin pens to ensure she understood the process. The director of nurses (DON) was interviewed on 12/14/23 at 11:23 a.m. The DON said she was unaware the nursing staff did not know they needed to prime and complete a safety check before administering insulin via a pen. The DON said nurses were taught how to administer insulin using an insulin pen during orientation. The DON said this would be a good opportunity to provide some additional education to the nurses and would follow up accordingly on the same day of the interview.

Based on record review and interview, the facility failed to designate an infection preventionist (IP) that completed specialized training in infection prevention and control. Specifically, the infection preventionist worked as a part time employee and had worked as the IP for one year and had not completed the education and training requirement prior to assuming the duties of the position. Findings include: I. Facility policy The Infection Prevention policy was requested on 7/7/23 and the Infection Prevention Control Committee plan, dated July 2023, was received on 7/7/23 from the director of nursing (DON). The plan documented in pertinent part: Our facility has an infection prevention and control program. The objectives may be obtained as a component of the quality assurance and performance improvement committee (QAPI) or by having a separate infection prevention control committee. Duties included: assist in reviewing food handling practices, assist in monitoring and assessing facility-wide infection prevention and control practices, and provide the QAPI committee with a copy of the minutes of all infection prevention and control meetings held. The infection preventionist will oversee the infection prevention and control program and report to the infection prevention and control committee. The administrator will be responsible for oversight of the infection prevention and control program. II. Record review Observations on 7/7/23 revealed staff and volunteers were not trained and using proper hand hygiene and glove usage during meal services. Cross-reference F812 for food sanitation. The certification for the IP was requested on 8/9/23 at 9:20 a.m. and received at 12:14 p.m. The documentation revealed the IP completed the 15 required modules over time that began on 12/12/21 and ended 2/4/23. On 8/9/23 (during the survey) the IP completed the Training Plan Proof of Completion for Nursing Home Infection Preventionist Training Course. III. Interview The IP and the director of nursing were interviewed together on 8/2/23 at 9:30 a.m. The IP said she was a registered nurse and worked for the facility in a part-time capacity. The IP said she had been working as the IP for about one year. The IP said she had an IP certificate issued by the State of Colorado. The IP said that when she was not present the DON and the Infection Prevention Committee worked together on infection prevention in the facility. The IP and DON said the IP did not participate or attend the facility quality assurance committee and the committee did not have improvement programs that focused on infection prevention.

Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to -Ensure appropriate hand washing and glove usage in the main dining room; -Ensure glassware and silverware was handled properly in the main dining room; and, -Ensure hair restraints were worn in a serving kitchen. Findings include: I. Ensure appropriate hand washing and glove usage in the main dining room A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. (Retrieved 8/9/23). -Ready-to-eat is considered a food without further washing, cooking, or additional preparation and that is reasonably expected to be consumed in that form. -Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. B. Facility policy and procedure The Handwashing/Hand Hygiene policy, undated, was provided by the nursing home administrator (NHA) on 8/9/23 at 9:14 a.m. It revealed in pertinent part, All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Residents, family members and/or visitors will be encouraged to practice hand hygiene. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: when hands are visibly soiled; and, after contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. The Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, undated, was provided by the NHA on 8/9/23 at 9:14 a.m. It revealed in pertinent part, Contact between food and bare (ungloved) hands is prohibited. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced: after direct contact with residents; after assisting with medical treatments; between handling raw meats and ready-to-eat foods; and between handling soiled and clean dishes. The use of disposable gloves does not substitute for proper handwashing. Gloves are worn when directly touching ready-to-eat foods. C. Observations During a continuous observation on 8/7/23 beginning at 11:28 a.m. and ended at 12:17 p.m. the following was observed: -The volunteer grabbed two Styrofoam bowls that had dessert in them. She put her fingers into the bowls and pinched them together, picking up two bowls with one hand. The volunteer got frosting on her finger by sticking her hand into the bowls. The volunteer licked her fingers and then picked up more bowls in the same manner and delivered the desserts to residents around the dining room. -Without performing hand hygiene, the volunteer began assisting a resident with eating. -The volunteer then moved a chair in the dining room. She then got a drink for another resident. The volunteer delivered meals to residents and passed out more desserts. The volunteer touched her face and then began passing out more resident meals. The volunteer answered her phone and was talking on the phone. The volunteer remained on the phone and was passing out meals to residents. While she remained on the phone she served residents soup. The volunteer put her phone in her pocket and went back to assisting the resident with eating. The volunteer did not perform hand hygiene. -At 11:46 a.m. the volunteer served soup to more residents and assisted a resident in opening his bag of crackers. -At 11:57 a.m. the volunteer touched the leg of a resident and then touched another resident's handles to their wheelchair. -At 11:49 a.m. the volunteer served a resident her meal and then began assisting the resident with eating. The volunteer had not performed hand hygiene. -At 11:55 a.m. the volunteer was helping the same resident eat. -At 11:58 a.m. The volunteer touched another resident's silverware. -At 12:04 p.m. The volunteer walked over to another table and put her hand on the table. The volunteer went back to assisting the same resident with eating. She did not perform hand hygiene. During a continuous observation on 8/7/23 beginning at 3:44 p.m. and ended at 4:56 p.m. the following was observed: -At 3:59 p.m. dietary aide (DA) #1 left the serving kitchen with gloves on and was holding a serving ladle. DA #1 bean serving soup to residents. DA #1 moved a resident's walker and then served another bowl of soup. DA #1 moved the cart with the soup on it to another table. DA #1 served another bowl of soup. -4:15 p.m. DA #1 was collecting dirty dishes and putting them on the dirty dish cart. DA #1 stopped picking up dirty dishes and went to the handwashing sink. He dispensed a paper towel and used it to wipe his soiled gloves. DA #1 did not take his gloves off and then entered the kitchen and picked up a resident's meal ticket. DA #1 left the serving kitchen and said he was going to go up to the main kitchen. DA #1 still had the same dirty gloves on. DA #1 was stopped outside the dining room and was handed three Styrofoam food containers. DA #1 handed the food containers to the certified nurse aide (CNA) in the dining room. DA #1 left the dining room with the dirty gloves on and entered the elevator. -At 4:23 p.m. hospitality aide (HA) #1 picked up a piece of toast with her bare hands and began putting butter on it. -At 4:33 p.m. HA #1 assisted another resident butter their toast by touching the toast with her bare hands. -At 4:40 p.m. an unidentified CNA washed her hands. She did not dispose of the dirty paper towel. She was holding the dirty paper towel and picked up a resident's dessert with the same hand. The dirty paper towel touched the side of the bowl. -At 4:41 p.m. DA #1 had gloves on. DA #1 picked up dirty clothing protectors and put them into the dirty linen container. DA #1 began picking up dirty dishes and putting them on the dirty dish cart. -A resident asked DA #1 for a spoon. With the same gloved hands, he picked up a clean spoon and handed it to the resident. DA #1 patted the resident on the back with his dirty gloved hand. DA #1 went back to clearing dirty dishes. -An unidentified CNA asked DA #1 to put a resident's sandwich and chips onto a plate. Without taking of his gloves or performing hand hygiene, DA #1 took the sandwich out of the Styrofoam container and put it onto a plate. DA #1 then reached into an opened bag of chips and put a handful of chips onto the plate. -At 4:47 p.m. DA #1 went back to clearing dirty dishes. D. Staff interviews The volunteer was interviewed on 8/8/23 at 1:09 p.m. She said her niece was a resident at the facility. Volunteer said she wanted to help out, so she began volunteering at the facility. DA #3 and DA #4 were interviewed on 8/8/23 at 3:17 p.m. DA #3 said they were required to wash their hands frequently when in the dining room. DA #3 said hand hygiene should be performed when entering the dining room, entering the serving kitchen, between tasks, before and after glove usage and whenever their hands became soiled. DA #4 said gloves should be worn when handling ready-to-eat foods. CNA #1 was interviewed on 8/8/23 at 3:21 p.m. CNA #1 said hand hygiene should be conducted after each task, including before and after glove usage. CNA #1 said ready-to-eat food should be handled using bowls and silverware. CNA #1 said ready-to-eat foods should not be touched with bare hands. HA #1 was interviewed on 8/8/23 at 4:21 p.m. She said hand hygiene should be performed frequently. HA #1 said when handling ready-to-eat foods she would wash her hands and then touch the food without gloves. HA #1 said she had not received any specific training on handling ready-to-eat foods. The DM was interviewed on 8/8/23 at 4:23 p.m. The DM said hand hygiene should be conducted when entering the dining room and the kitchen. She said hand hygiene should be conducted before and after glove usage. The DM said she had not conducted any recent hand hygiene in-services. The NHA and the director of nursing (DON) were interviewed on 8/8/23 at 4:34 p.m. The DON said gloves should not be worn in the dining room unless handling ready-to-eat foods. The NHA said hand hygiene should be conducted often in the dining room. The NHA said hand hygiene should be conducted after touching dirty dishes, before and after glove usage. The NHA said all staff had competencies in June 2023, which included hand hygiene. The NHA said they would conduct a training on hand hygiene. The NHA said the volunteer was brought on as a volunteer a couple weeks ago. The NHA said the volunteer was a resident's family member. The NHA said the facility completed a competency when the volunteer began helping out in the dining room. The NHA said they would conduct hand hygiene training with the volunteer. The infection preventionist (IP) and the DON were interviewed on 8/9/23 at 9:43 a.m. The IP said hand hygiene should be conducted frequently in the dining room. The IP said hand hygiene should be conducted before and after wearing gloves and after touching contaminated items such as dirty dishes. The IP said ready-to-eat foods should not be touched with bare hands. II. Ensure glassware and silverware was handled properly in two of four dining rooms. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It revealed in pertinent part, single-service and single-use articles and cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. (Retrieved 8/9/23). B. Facility policy and procedure The Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, undated, was provided by the NHA on 8/9/23 at 9:14 a.m. It revealed in pertinent part, Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. C. Observations During a continuous observation on 8/7/23 beginning at 11:28 a.m. and ended at 12:17 p.m. the following was observed: -At 11:28 a.m. the volunteer was carrying several cups of beverages. She had a cup of coffee held against her scrub top using her forearm. -At 11:31 a.m. The volunteer provided a resident a beverage. The volunteer was holding the top of the cup with all five of her fingers surrounding the rim of the cup. -At 11:37 a.m. HA #1 was holding one cup in each hand. HA #1 was holding the cups with all five fingers around the top rim of the cup. -HA #1 passed another cup to a resident by holding the top of the glass with all five fingers. During a continuous observation on 8/7/23 beginning at 3:44 p.m. and ended at 4:56 p.m. the following was observed: -DA #1 grabbed a soup spoon to hand to a resident with their soup. DA #1 touched the spoon by the part of the spoon that would hold the soup. D. Staff interviews DA #2 and DA #4 were interviewed on 8/9/23 at 3:17 p.m. DA #2 said glassware and cups should be handled from the bottom of the cup. DA #2 said touching the rim of the glass could contaminate the glass. DA #4 said silverware should be handled by the handle. DA #4 said silverware should not be touched where a resident's mouth would touch, as it could contaminate the silverware. The dietary manager (DM) was interviewed on 8/8/23 at 4:23 p.m. The DM said staff should hold glasses by the bottom of the glass and silverware should be grabbed by the handle. The NHA and the DON were interviewed on 8/8/23 at 4:34 p.m. The DON said silverware should be picked up by the handle and glasses should be handled from the bottom. III. Ensure hair restraints were worn properly A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed foods; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. (Retrieved 8/10/23). B. Facility policy and procedure The Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices policy, undated, was provided by the NHA on 8/9/23 at 9:14 a.m. It revealed in pertinent part, Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. C. Observations During a continuous observation on 8/7/23 beginning at 11:28 a.m. and ended at 12:17 p.m. the following was observed: -DA #2 was in the serving kitchen in the main dining room. She had long sweeping bangs covering her forehead. Her bangs were not contained in a hair restraint as she served food to residents. D. Staff interviews The DM was interviewed on 8/8/23 at 4:23 p.m. The DM said hair nets should restrain all hair and should be worn when serving food.

Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for one (#4) of three residents reviewed for eating assistance out of seven sample residents. Specifically, the facility failed to provide the necessary assistance for Resident #4 who required physical assistance and encouragement with eating. Findings include: I. Facility policy and procedure The Assistance with Meals policy, revised March 2022, was provided by the nursing home administrator (NHA) on 8/10/23 at 5:47 p.m. It revealed in pertinent part, Facility staff will serve resident trays and will help residents who require assistance with eating. II. Resident #4 A. Resident status Resident #4, age 80, was admitted on [DATE]. According to the August 2023 computerized physician orders (CPO), the diagnoses included respiratory failure, chronic obstructive pulmonary disease (COPD), dementia, glaucoma (vision loss) and dysphagia (difficulty swallowing). The 7/18/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status with a score of five out of 15. She required extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. She needed supervision with one person physical assistance for eating. B. Observations and resident interview During a continuous observation on 8/7/23 beginning at 11:28 a.m. and ended at 12:17 p.m. the following was observed: -At 11:55 a.m. Resident #4 had her meal in front of her consisting of a chicken leg, dessert, soup, potatoes and crackers. Another resident sitting next to Resident #4 told Resident #4 to pick up her chicken leg and eat it. -At 11:56 a.m. Resident #4's tablemate asked Resident #4 if she could cut the meat of the chicken bone for her. -At 11:58 a.m. Resident #4's tablemate picked up Resident #4's chicken and explained to her how to eat it off the bone. -At 12:02 p.m. Resident #4 asked for more to drink and she was given another soda. -At 12:04 p.m. Resident #4 had taken a few bites of her soup and potatoes. -At 12:08 p.m. certified nurse aide (CNA) #2 walked over to Resident #4 and asked her if she was doing alright. CNA #2 did not encourage or offer meal assistance to Resident #4. -At 12:16 p.m. hospitality aide (HA) #1 approached Resident #4 and asked her if she wanted to go to the television room and took her out of the dining room. -Resident #4 did not eat her chicken, crackers, dessert or potatoes. She took a couple bites of her soup. During a continuous observation on 8/7/23 beginning at 3:44 p.m. and ended at 4:56 p.m. the following was observed: -At 3:44 p.m. the table that Resident #4 sat for dinner that had four place settings. -At 4:02 p.m. an unidentified CNA assisted Resident #4 to the dining room. -At 4:07 p.m. Resident #4 was served a bowl of soup and was given a soup spoon. Four other residents were sitting at the same table as Resident #4. Resident #4 did not have a silverware set-up since there were only four place settings on the table. Resident #4 was not given any additional silverware during the meal. -At 4:09 p.m. Resident #4 was not eating her soup. -At 4:14 p.m. Resident #4 took two small bites of her soup. Resident #4 had not been provided with a beverage. -At 4:19 p.m. Resident #4 received her dinner plate. Resident #4 was not given any silverware or a beverage with her meal. -At 4:22 p.m. Resident #4's meal remained in front of her untouched. -At 4:26 p.m. Resident #4 remained in the dining room with her meal in front of her. Resident #4 did not have silverware or a beverage. -At 4:32 p.m. Resident #4 poked the tuna noodle casserole with her finger. Resident #4 only had a soup spoon. -At 4:36 p.m. Resident #4 asked for a cup of coffee. An unidentified CNA got Resident #4 a cup of coffee and helped her put creamer into it. The unidentified CNA put Resident #4's soup spoon into the coffee cup to stir the creamer in. The unidentified CNA told Resident #4 that she had tuna noodle casserole for dinner. The unidentified CNA did not provide Resident #4 with silverware or encouragement to eat her meal. -At 4:42 p.m. Resident #4 pushed her plate away and said I don't know whose plate that is. -At 4:45 p.m. Resident #4 finished her coffee. -At 4:51 p.m. Resident #4 remained in the dining room with her meal in front of her. Resident #4 had not received encouragement, cueing or silverware to consume her meal. -At 4:56 p.m. CNA #1 helped Resident #4 put her feet on the petals of her wheelchair and assisted Resident #4 out of the dining room. -Resident #4 did not eat her dinner and took two bites of soup. Resident #4 did not receive encouragement, assistance or silverware to eat her meal. During a continuous observation on 8/9/23 beginning at 9:27 a.m. and ended at 9:51 a.m. the following was observed: -At 9:27 a.m. Resident #4 was lying in bed with her bedside table over the bed. Resident #4 said she was not aware she had been served breakfast. Resident #4 said she was unable to reach her breakfast sandwich and hash browns. Resident #4 said it would be difficult for her to eat lying down and the bedside table was too far away for her to reach. -At 9:28 a.m. the activities supervisor (AS) entered Resident #4's room and asked her if she would like to attend communion. Resident #4 said yes she would like to attend. The AS said he would ask the nursing staff to help her get up and ready for her day, so she could attend. -At 9:35 a.m. registered nurse (RN) #1 entered Resident #4's room and assisted the resident in fixing her oxygen tubing. -At 9:38 a.m. RN #1 left Resident #4's room and CNA #1 entered the room and closed the door. -At 9:40 a.m. CNA #2 entered Resident #4's room. -At 9:42 a.m. CNA #2 left Resident #4's room and disposed of an incontinence brief and then re-entered Resident #4's room. -At 9:51 a.m. CNA #1 exited Resident #4's room with her breakfast. CNA #1 said Resident #4 did not eat any of her breakfast. The egg sandwich and hash brown remained on Resident #4's plate. C. Record review The ADL care plan, initiated on 7/28/23, revealed Resident #4 required assistance with her ADLs. The interventions included: assisting her with oral care as needed, providing one person assistance with meals, providing one person assistance with dressing, providing set-up assistance with meals, encouraging the resident to ask for help, providing peri care after each incontinent episode, utilizing disposable incontinence products as needed, providing a wheelchair for mobility, screening the resident for therapy needs quarterly and as needed, providing one person assistance with toileting and providing two person assistance with the gait belt for transfers. The nutrition care plan, initiated on 7/28/23, revealed Resident #4 was at nutritional risk related to poor vision, pain and shortness of breath. The interventions included: providing the diet as ordered, encouraging adequate oral intake as needed, monitoring for signs or symptoms of difficulty chewing or swallowing, monitoring labs as ordered and notifying the family and physician of any significant weight changes. -However, through observations Resident #4 did not receive encouragement at meals. The visual impairment poor vision care plan initiated on 7/28/23 revealed Resident #4 had a visual impairment and poor vision related to glaucoma. The interventions included: adapting the environment to the resident's needs to ensure she was able to recognize objects, ensuring the call light was within reach, giving verbal cues as necessary to ensure Resident 34 knew where her walker and wheelchair was, keeping the environment free of clutter and orienting the resident to her surroundings as needed. III. Staff interviews CNA #1 was interviewed on 8/9/23 at 9:51 a.m. CNA #1 acknowledged Resident #4 did not eat her breakfast. CNA #1 said when Resident #4 was up for meals she was able to feed herself and did not need any assistance or cueing to consume her meals. Licensed practical nurse (LPN) #1 was interviewed on 8/9/23 at approximately 10:00 a.m. LPN #1 said if nursing staff noticed a resident was not eating well, they would refer to speech therapy for assistance. The registered dietitian (RD) was interviewed on 8/9/23 at 10:09 a.m. The RD said she was only in the building one day a week and worked remotely the rest of the week. The RD said dietary staff and nursing staff were able to report to her or therapy if they noticed a resident was needing more assistance at meals. The RD said Resident #4 likely needed cueing or assistance with meals and she would discuss it with the interdisciplinary team. The RD said CNA #1 should have encouraged Resident #4 to eat prior to taking her back to her room after she had dinner on 8/7/23. The dietary manager (DM) was interviewed on 8/9/23 at 10:33 a.m. The DM said she was often in the dining room during meals and would notice if residents needed more assistance with meals or were not eating their meals. The DM said she had been very busy and had not been in the dining room during meals to notice that Resident #4 was not eating well and could have used cueing or assistance. The director of rehabilitation (DOR) was interviewed on 10/9/23 at 10:45 a.m. The DOR said occupational therapy had recommended Resident #4 to be in an upright position with proper position at meals. The DOR acknowledged Resident #4 may have needed cueing or assistance at meals, since she had not been eating well for several meals. At 10:49 a.m. the director of nursing (DON) and the NHA joined the interview. The DON said if a nursing staff member noticed a resident was not eating well they should report it to therapy or herself to add to the residents plan of care to provide more assistance at meals. The NHA and DON said they would review Resident #4 and update her plan of care for more oversight at meals.

Based on observation, interviews and record review, the facility failed to ensure the necessary care and treatment to prevent the development of pressure injuries for one (#61) of two residents reviewed of 44 sample residents. The facility failed to provide the necessary equipment, interventions and care timely for a resident who was identified to be at risk for developing pressure ulcers due to the presence of a right femoral fracture and use of an immobilizing device. Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was hospitalized from 7/26/22 to 8/3/22 following a fall and subsequent fracture of her right femur. A skin assessment was completed upon Resident #61's readmission to the facility on [DATE]. It indicated Resident #61 was at risk for developing pressure ulcers and indicated bruising to upper extremities. No additional skin assessments were completed until 8/21/22 in which Resident #61's skin was indicated to be intact. On 8/29/22 staff observed a dark purple area draining on the resident's right heel. The wound physician assessed the resident and it was determined that the resident had an unstageable right heel deep tissue injury (DTI). I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 9/12/22, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy The Pressure Ulcer/Skin Breakdown policy and procedure, revised April 2018, was provided by the nursing home administrator (NHA) on 9/1/22 at 3:00 p.m. It read, in pertinent part, The nursing staff and practitioner will assess and document an individual's significant risk factor for developing pressure ulcers, for example immobility. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings, and application of topical agents. III. Resident #61 A. Resident status Resident #61, age 73, was admitted on [DATE] and readmitted [DATE]. According to the August 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 8/18/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. It indicated the resident required extensive, two person assistance for activities of daily living. It indicated the resident utilized a wheelchair for mobility. It indicated the resident was at risk for pressure ulcers and had a stage 2 pressure ulcer that was present at admission. -The MDS assessment documented the resident had stage 2 that was present on admission, it was not indicated in her medical record (see below). B. Resident interview Resident #61 was interviewed on 8/29/22 at 11:21 a.m. She said she had a fall at the end of July 2022 and broke her leg. She said since the fall she was unable to do anything on her own and had to stay in her wheelchair. She said there was a wound on her heel that the staff noticed the previous day. The resident was sitting in her wheelchair with a foot cradle. The resident had a soft brace on her foot that was ankle length. She did not have protective (also called bunny) boots on her feet. A bandage was observed on the resident's right heel during the interview. Resident #61 was interviewed again on 8/31/22 at 9:01 a.m. She said the wound on her heel was noticed by staff on 8/28/22. She said she did not have any pain related to the wound. She said since her right leg was broken she had to wear a large brace and her right leg had been swollen. She said she was unable to move her right leg on her own. She said when she returned from the hospital she did not wear any protective items on her foot but staff would float her legs if she was in bed. She said she did not prefer to be in bed and wanted to sit in her wheelchair for most of the day. She said a nurse told her she probably got the wound from her foot rubbing up against the cushion on her wheelchair. She said when she was in her wheelchair she just had socks on. The resident was observed in her wheelchair with the foot cradle and wore a bunny boot on her right foot. C. Record review The resident was in the hospital from 7/27/22 to 8/3/22 where she had been admitted with right femur fracture. A skin assessment was completed upon Resident #61's readmission to the facility on [DATE]. It indicated Resident #61 was at risk for developing pressure ulcers. It indicated the resident had a pressure relieving device on her bed and wheelchair. Skin issues observed included shearing to coccyx, bruising to abdomen, bruising to left wrist and forearm, and bruising to right bicep and fingers. The 8/4/22 progress note indicated the resident returned from the hospital following a right femur fracture. It indicated the resident had a right knee brace and would need to utilize a hoyer (mechanical) lift for transfers. The 8/7/22 progress note indicated the resident required one person assistance for repositioning and two person assistance for hoyer use. A Braden Scale for Predicting Pressure Sore Risk was completed again on 8/17/22. It indicated the same results as the assessment completed on 8/3/22 (see above). A skin check was completed on 8/21/22. It indicated the resident's skin was intact. No additional notes were included. -No skin assessments were completed from 8/4/22-8/21/22. The 8/29/22 a progress note indicated a certified nurse aide (CNA) noticed the residents legs were weeping. Upon further assessment it was observed that the resident had a dark purple area that was draining on her right heel. The physician was notified and orders for wound care were obtained. The 8/29/22 a progress note indicated the resident was assessed by the wound physician and had a right heel deep tissue injury (DTI). Orders were obtained for [MEDICATION(S)] and dressing to be applied. Resident #61 was assessed by the wound physician on 8/29/22. The notes indicated the resident had an unstageable DTI to her right heel. It indicated the measurements as 3.5 centimeters by 3.5 centimeters. It indicated there was light serous exudate (fluid). It indicated slough of 5%, granulation tissue of 20%, and viable tissues at 20%. It indicated the necrotic tissue was removed by the physician. The wound was cleaned and 0.62 centimeters of devitalized tissue were removed at a depth of 0.1 centimeters with healthy bleeding tissue observed. A clean dressing was applied following the procedure. Recommendations included to off load the wound and float heels in bed. The 8/30/22 a progress note was completed that indicated the resident had a DTI to right heel with a dry intact dressing in place. It indicated the resident was wearing bunny boots on her feet and orders were placed for occupational therapy to evaluate for wheelchair positioning. The August 2022 CPO revealed the following: -Hinged knee brace to right lower extremity in extension to be work continuously, ordered 8/3/22; -Float heels every shift as tolerated, ordered on 8/4/22; -Apply mattress overlay, ordered on 8/12/22; -Cleanse right heel with wound cleaner, apply [MEDICATION(S)] and island dressing daily and as needed, ordered on 8/29/22; -Apply bunny boot to right heel, ordered on 8/30/22; and, -Proheal critical care (protein supplement) 30 milliliters two times a day for impaired skin, ordered on 8/30/22. The skin care plan, revised 8/29/22 indicated Resident #61 was at risk for skin breakdown related to [CONDITION(S)], fragile skin, and immobility. Interventions included wound care specialist to evaluate and treat, air overlay on mattress, bunny boot to right foot, and float heels in bed. -The skin plan did not indicate the resident had the wound to her right heel and did not include the foot cradle to her wheelchair. D. Staff interviews Registered nurse (RN) #1 was interviewed on 8/31/22 at 8:52 a.m. She said Resident #61 had a fracture and returned from the hospital with a brace on her right leg that needed to be worn at all times. She said the resident was non-weight bearing on her right leg. She said if a resident was non-weight bearing, heel protectors should be worn and pillows should be utilized to float the heels. She said the resident did not have heel protectors when she initially returned from the hospital but her heels were being floated when she was in bed. CNA #2 was interviewed on 9/1/22 at 9:18 a.m. She said Resident #61 had a brace on her right leg. She said the resident did not wear a boot for heel protection upon return from the hospital, but her wheelchair did have a padded cushion. The director of rehabilitation (DOR) was interviewed on 9/1/22 at 10:38 a.m. He said the therapy department received orders to complete a wheelchair assessment because of the resident's leg brace. He said pressure needed to be taken off of her leg. He said the resident currently had a foot cradle on her wheelchair that was made of foam cushion and also wore bunny boots to protect her heels. -The foot cradle was not indicated on the resident's care plan or in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Licensed practical nurse (LPN) #1 was interviewed on 9/1/22 at 11:30 a.m. The director of nursing (DON) was present for the interview. LPN #1 said she was the facility's wound nurse. She said Resident #61's wound was reported to her on 8/29/22 and had been found by nursing staff the previous day. She said it appeared to be a ruptured blister and was purple. She said she clarified the treatment orders that day and the wound physician was in the building so he assessed it as well. She said Resident #61 had orders to float her heels since she got back from the hospital on 8/3/22. She said her wheelchair had a padded foot cradle as well. She said bunny boots were not used when she returned from the hospital as bunny boots were not automatically utilized if someone returned from the hospital with immobility of an extremity. She said the resident had an air overlay on her bed but not an air mattress because the resident did not want one. She clarified that interventions that were put into place upon discovery of the DTI included the air mattress overlay, pillows for floating heels, repositioning bars on bed, padded foot cradle on her wheelchair, bunny boots, and a therapy evaluation for wheelchair positioning. She said she believed the wound occurred due to positioning and the wheelchair. She said since the resident had a brace on her right leg, the leg was fixed into a straight position and was sitting on the foot cradle consistently. She said the resident was unable to move her right leg independently and was dependent on staff for repositioning. Certified nurse aide (CNA) #1 was interviewed on 9/1/22 at 1:38 p.m. She said Resident #61 had a brace on her right leg. She said she also wore a boot on her right foot to protect her heel. She said she was unsure what interventions were in place when the resident returned from the hospital with her broken leg.

Based on interviews and record review the facility failed to ensure the environment remained free from accidents and hazards and that residents received adequate supervision and assistive devices to prevent accidents for two (#61 and #7) of three residents out of 44 sample residents. Resident #61 was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], muscle weakness, lack of coordination, and abnormalities of gait and mobility. The resident required extensive, two person assistance for toileting and transfers. On 7/26/22, the resident fell in her bathroom during a transfer with one certified nurse aide (CNA) assisting. The resident was sent out to the hospital on 7/27/22 due to increased pain to her right lower extremity. At the hospital, it was discovered that the resident had a fracture to her right femur. Due to the facility not following the resident's transfer requirement of two staff as indicated by the 7/22/22 minimum data set assessment (four days prior to the fall), the resident had a fall that resulted in a fracture to the right femur. Resident #7 had a known history of falling. The resident fell on [DATE] and complained of pain following the fall. She reported to a physician assistant after 6/3/22 that she had fallen three other times in her room. The facility failed to investigate the other reported three falls. The facility sent the resident for an x-ray on 6/10/22 where a fracture of her left foot was confirmed. The resident was determined to have a fractured foot for seven days before it was discovered and a course of action was provided. Findings include: I. Facility policy The Falls policy and procedure, revised October 2010, was provided by nursing home administrator (NHA) on 9/1/22 at 3:00 p.m. It read, in pertinent part Falling may be related to underlying clinical conditions and functional decline, medication side effects, and/or environmental risk factors. Residents must be assessed in a timely manner for potential causes of falls. If there is evidence of a significant injury, nursing staff will help the resident to a comfortable sitting, lying, or standing position, and then document relevant details. II. Resident #61 A. Resident status Resident #61, age 73, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), diagnoses included [CONDITION(S)], muscle weakness, lack of coordination, and abnormalities of gait and mobility. The 8/18/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status score of 15 out of 15. It indicated the resident required extensive, two person assistance for activities of daily living. It indicated the resident utilized a wheelchair for mobility. B. Resident interview Resident #61 was interviewed on 8/29/22 at 11:18 a.m. She said she had a fall at the end of July 2022 and broke her leg. She said a CNA witnessed the fall. She said the fall happened in her bathroom while she was toileting. She said since the fall she was unable to do anything on her own and had to stay in her wheelchair. Resident #61 was interviewed again on 8/31/22 at 9:01 a.m. She said when she fell in her bathroom a lift device was not being used. She said her knees gave out and she went down. She said the CNA tried to help but was unable to stop her from falling. She said she had a gait belt on at the time. Resident #61 was interviewed on 9/1/22 at 9:07 a.m. She said one CNA was present when she fell in her bathroom. She said when she needed assistance with toileting she only needed one person. She said a lift device had been used with her before but it was not used consistently because she could stand with assistance. She said when she was falling her knee folded and she could not get up. She could not recall what part of her legs hit the floor but they were twisted when she was falling. She said the CNA attempted to help her sit on her wheelchair but she asked the CNA to move the wheelchair as she was falling. She said she had increased pain in her leg and was sent to the hospital shortly after. C. Fall investigation The director of nursing (DON) provided the fall investigation on 8/31/22 at 11:35 a.m The investigation indicated that on 7/26/22, a CNA was assisting Resident #61 to a standing position from the toilet. The CNA pulled the resident's pants up and the resident said she needed to sit back down. The resident sat on the edge of the toilet and the CNA attempted to assist the resident to sit further back on the toilet when the resident began to slide off the toilet. The CNA was able to push the wheelchair away and lower the resident to a seated position on the floor. The CNA then laid the resident on her back. The resident was assessed for injury and no injuries were identified though the resident reported pain to her right knee. The resident was assisted to bed by four staff members. Pain medications were administered. The root cause analysis indicated the resident's leg gave out and the interventions put into place following the event were two person transfers and recommendation of a physical therapy evaluation. The report indicated the resident was sent to the hospital on 7/27/22 due to increased pain in her right knee. A right femur fracture was identified at the hospital. D. Record review Progress notes from 7/27/22-9/1/22 revealed the following: -On 7/27/22 a progress note indicated Resident #61 had a fall on 7/26/22. It indicated the resident was at a level 4 out of 10 (on a pain scale with 10 being the worst) for pain in her right knee. It indicated no redness or swelling was observed. -On 7/27/22 a progress note indicated Resident #61 had an assist to the floor on 7/26/22. It indicated her pain was at a 4 out of 10 and she could not move her right leg but no bruising or swelling was observed. It indicated that a lift device was needed for transfers because the resident could not put weight on her right leg. It indicated the physician was notified. -On 7/27/22 a progress note revealed Resident #61 was sent out to the hospital for pain to her right leg. -On 8/4/22 a progress note was completed that indicated Resident #61 had returned from the hospital with a diagnosis of right femur fracture. The note indicated the resident would need a Hoyer lift for transfers. The MDS assessment was completed on 7/22/22, four days prior to the fall. It indicated Resident #61 required extensive, two person assistance for transfers and toileting. The fall care plan was updated on 7/26/22 to include that Resident #61 required two people for transfers. The activities of daily living care plan, revised 8/25/22, indicated Resident #61 required two person assistance with transfers and the hoyer lift to be used as needed. The hospital report revealed Resident #61 was admitted on [DATE]. The report indicated the resident stated she was getting up from her wheelchair using a lift device and fell . It indicated that after the fall the resident had severe pain in her right lower extremity. The report indicated the resident said she had been feeling weaker following a urinary tract infection and related hospital stay from 7/15/22 to 7/18/22. It indicated the resident said she was too weak to stand on her own and had been using a lift device for transfers. An orthopedic consultation was completed at the hospital on 7/28/22. The report revealed the resident had right knee pain due to a fall from a mechanical lift. The report indicated recommendations were non surgical treatment of right femur fracture, immobilizer to right leg, non-weight bearing to right leg, and skilled physical and occupational therapy treatments were ordered. The resident was discharged from the hospital on 8/3/22. The discharge summary indicated the resident had a fall from a mechanical lift device while transferring from her wheelchair in the bathroom. It indicated the resident had a right femur fracture and would need outpatient orthopedic consultation. E. Staff interviews CNA #2 was interviewed on 9/1/22 at 9:18 a.m. She said Resident #61 was one person assist for toileting and transfers prior to her fall in July 2022. She said staff did not use the Hoyer lift with her prior to the fall. She said because of her injuries from the fall, staff needed to use the Hoyer lift for all transfers. CNA #1 was interviewed on 9/1/22 at 1:39 p.m. She said she had been working at the facility for a few weeks and knew Resident #61 utilized a Hoyer lift for transfers. She was unsure what level of assistance the resident needed prior to her fall in July 2022. Registered nurse (RN) #1 was interviewed on 9/1/22 at 10:34 a.m. She said prior to the fall, Resident #61 was one person assist for transfers. She said shortly before the fall the resident would need two person assistance on occasion because she had some weakness. She said because of the resident's fracture, the Hoyer was utilized. The director of rehabilitation (DOR) was interviewed on 9/1/22 at 10:38 a.m. He said the resident currently required a Hoyer lift for transfers. He said he was unsure if a Hoyer lift was utilized prior to the fall in July 2022. He said the therapy department had not worked on transfers with the resident since 2021. He said Resident #61 was discharged from physical therapy on 7/18/22 and no recommendations were made for transfers at discharge. The director of nursing (DON) was interviewed on 9/1/22 at 1:14 p.m. She said Resident #61 was being assisted in the bathroom by a CNA when she had her fall. She said at the time, Resident #61 was able to stand on her own. She said when the CNA pulled the resident's pants up, the resident had to sit down but slid off the toilet. She said the CNA lowered the resident to the floor into a seated position and went to get help. She said a Hoyer lift was not being used and was unsure why that was documented in the hospital report. She said staff should follow the transfer status on the MDS which would also be in the care plan. She said she did not know the MDS indicated this resident was a two person assistance for transfers and toileting. She said floor staff were reporting using one or two people for transfers around the time of the fall. III. Resident #7 A. Resident status Resident #7, age 73, was admitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnoses included spinal stenosis (narrowing of spaces in the spine), [CONDITION(S)] (CPOD), anxiety disorder, muscle weakness, unsteadiness on feet, pain in right leg, [CONDITION(S)], and hypertension (high blood pressure). The 6/4/22 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision with bed mobility, transfers, walking in her room, dressing, eating, toilet use and personal hygiene. The resident did not reject cares from staff. The resident was steady at all times when she walked, when moved from a seated to standing position, when turned around, when moving on and off the toilet. The five day look back revealed the resident had frequent pain, received pain medication, the resident's pain intensity scored a 6 (out of 10 with 10 being the worst on the scale) indicating strong pain that interferes with normal daily activities and the pain made it difficult to concentrate. B. Resident interview Resident #7 was interviewed on 8/30/22 at 9:01 a.m. She said a few months ago she fell out of bed and broke her left foot. She said she had to stay in bed a lot after the fall because her foot hurt. She said she did not know why the facility took so long to get her an x-ray but when she finally received one it revealed she fractured her left foot. She said she had a lot of pain in her foot after she fell . She said a few days after the x-ray she started to wear a walking boot to protect her foot. She said breaking her foot was hard on her because she was very independent, walked up and down the hallways, and enjoyed visits with her many friends in the facility. C. Record review The admission comprehensive care plan, dated 3/3/22 and revised on 3/10/22 revealed the resident was at risk for falls due to history of falls, medication use, new environment, unsteady balance/gait, weakness, pain, muscle spasms. -The resident is at risk or has right thigh pain, muscle spasms, vertebra fracture and [CONDITION(S)]. -The resident will report relief of pain after receiving intervention/medications. -The resident's interventions included administering pain medications as ordered, assist in finding comfortable position in bed or wheelchair, assist with repositioning for comfort as needed, monitor for worsening of pain symptoms and report to physician as needed, and notify the physician if interventions are not consistently effective. The facility was to observe for pain every shift and as needed, and provide non-pharmacological interventions of the individual's choice which included repositioning and elevation. The nursing progress note on 6/4/22 revealed, Staff is called to resident's room by roommate. Resident #7 is found on the floor next to her bed with her legs tucked underneath her. 'I don't know how I got here' . She is assessed for injury and no injuries are noted at this time. She is assisted to a standing position and back to bed. Neuro (neurological) checks are initiated and vital signs are taken. All within normal limits. Notifications are made. -The nursing note was written on 6/4/22, the resident fell at 11:59 p.m. on 6/3/22. The nursing progress note on 6/5/22 revealed the resident revealed she had pain in the left rib/midsection area, and had a swollen left great toe. She was sore to the touch on the rib area and able to move her toe, put pressure on it, without pain. -The resident had pain levels that ranged from moderate to severe pain after the fall. An x-ray was not completed until seven days after the fall. The interdisciplinary team (IDT) report on 6/8/22 (the fall was five days previous) documented, Resident stated 'I don't know how I got here' she was not able to give any details of the fall. Resident has not had other past falls in the facility - isolated incident. Resident may have been attempting to sit up or self rise from bed. Recommendations included physical therapy evaluation and treatment. The nursing progress note on 6/8/22 revealed the physician assistant (PA) told the resident's nurse that the resident said she had fallen three other times in her room and did not report it to the staff. She also said she had toe pain and requested to see the doctor. The nurse then documented the resident told her that she had fallen three other times and not reported the falls to the staff. The resident said she was dizzy and fell while ambulating twice in her room but was able to get herself up. She said she did not have any injuries. She said she also did not report that she rolled out of bed in the middle of the night and went back to bed on her own. She said she was now aware she needed to call for help and have the nurse assess her for injuries anytime she fell . Resident told the nurse she had great toe pain and requested to see the doctor. The nurse documented there was no injury found on the toe. (see DON interview below) -However, the facility did not investigate the report of the resident falling three times as reported to the PA and nurse. The nursing progress note on 6/8/22 revealed, as needed (PRN) narcotic was given to decrease her pain level, but the note did not record where the pain was located. The radiology report on 6/10/22 revealed, There is a fracture involving the fifth metatarsal (middle bones in the foot between toe and ankle bone) and head first proximal phalanx (large bone in the toe closest to the foot). There is associated soft tissue swelling. No foreign body is seen. Conclusion, acute left foot fracture. -There were no nursing progress notes for four days following the radiology report. The nursing progress note on 6/15/22 revealed the resident was sent to ortho (orthopedic) and received an order to wear a boot on her foot at all times except in the shower. The comprehensive care plan on 6/15/22 revealed (the) walking boot on at all times until toe heels, may be removed for showers. D. Staff interviews The nurse practitioner (NP) was interviewed on 9/1/22 at 10:20 a.m. She said she began working at the facility in July. She said the PA who did visit Resident #7 no longer worked in the facility. She said she could not comment on the fall or the resident telling the PA that she had fallen three other times, or about the pain the resident told the PA about, or about that the resident wanted to see a doctor. She said that was before her time of employment and she knew nothing about what happened in June 2022. She said since she had started in July 2022 she had done a lot of work with Resident #7. The director of nursing (DON) was interviewed on 9/1/22 at 11:40 a.m. She said she did not know why it took about a week to x-ray Resident #7's foot. She said she could not comment on the fractured foot after the fall but she said she would look into the documentation and see why it took so long to get an x-ray and the walking boot. She said she did not know if the facility did a fall assessment after the resident told the PA she fell three times and did not inform the staff. She said if she found any documentation about the three falls, or why the facility did not order an x-ray for about a week after the fall on 6/3/22, she would provide the documentation. She said she would look into the electronic medical records to see if there were any physician notes about the three unwitnessed falls and if she found them she would provide those notes also. (see facility follow-up) E. Facility follow-up The facility did not provide any further documentation about Resident #7 during the survey (which ended 9/1/22) or after the survey via email. The facility did not send further documentation about why an x-ray was not done in a timely manner, nor was any information provided that a fall assessment had been performed after the PA told the facility that the resident had three more falls that she did not tell the facility about.

Based on observations, record reviews, and interviews, the facility failed to ensure one (#226) of four residents reviewed for pressure injuries out of 33 sample residents received care consistent with professional standards of practice. The facility failed to define and implement interventions that were consistent with resident needs, and to monitor and evaluate the effectiveness of interventions and re approach as necessary to prevent the development of pressure injuries for Resident #226. Resident #226 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed the resident did not have pressure wounds at the time of admission. An interview with the resident's primary care physician revealed the resident had a form of [CONDITION(S)]. The Resident's medical power of attorney (POA) decided against treatment as it was likely to lead to further impairment of the resident's health, including skin and susceptibility to infections and wounds (see interview below). Record review, observation, and interviews revealed the facility failed to implement timely interventions and adequately monitor his known risks to prevent pressure injuries. Resident #226's acquired a pressure wound within the first week of being admitted to the facility. - The pressure-reducing measures implemented upon admission included a pressure-reducing device for bed upon admission and positioning bars to the bed (2/12/21) were not tracked/utilized/implemented effectively to prevent a wound on the resident heel. A pressure-relieving air mattress was ordered for the resident on 2/22/21 after wound development. - Pressure-relieving measures for the resident's heels were not introduced until after wound development on 2/19/21. - Even though the resident was ordered double protein at meals (2/12/21) and consumed 50% meal intakes, two additional dietary supplementations for (healing/health promotion) were not implemented for nutritional support until 2/23/21 and a third supplement was added on 4/8/21. - Pillows and soft boots for pressure relieving were untracked and informally used by staff since the resident's admission and not ordered as an intervention and tracked until 2/22/21 after the wound had progressed. An off-loading pressure boot was not ordered until 3/1/21. Orders to float resident heels while in bed were not included until 3/12/21. - The heel wound modified the resident's ability to ambulate, confining him to a wheelchair, on 2/19/21, to relieve pressure to the wound. Modifications to the resident's wheelchair foot boxes were not implemented until 3/1/21. - The resident risk for skin breakdown admission assessments (Braden) did not account for all the health conditions and risk factors ([CONDITION(S)]) the resident was admitted with. - The wound was being followed by the facility wound nurse, however, an outside wound physician was not brought in to assess the left heel wound until 3/1/21, nine days after wound development. The left heel wound (initial assessment on 2/19/21) was unstageable, measuring 2.5 centimeters (cm) by (x) 2.0 cm by unmeasurable depth. Later the wound was assessed and determined to be a stage 4 on 3/15/21 measuring 2.5 cm x 3.5 cm by 0.1 cm. -As of 6/9/21, the facility had not developed a patient-centered care plan for skin integrity/pressure areas that identified and addressed the resident's initial resistance to floating heels with pillows, and a variety of boots (known as early as 2/14/21), attempting to do things independently and not understanding own limitations. The resident's skin condition continued to decline; as of 4/19/21, the resident had one active pressure injury and one that resolved on 3/15/21, (unstageable DTI to the right heel). The left heel wound had been improving measuring 2.9 cm x 2.0 cm x 0.1 cm on 6/3/21. The lower left leg/Achilles infection wound was discovered on 4/19/21, measured 10 cm x 3 cm x 0.5 cm. The lower left leg/Achilles wound progressed and measured 15 cm x 2.5 cm x 1.0 cm on 6/3/21. The wound physician determined this wound was unavoidable and possibly caused by a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interviews with facility staff revealed the facility was informally implementing bunny boots and pillows for the resident a couple of days after admission due to the resident propping his heels up on the footboard of his bed and the foot box of his wheelchair, the rejection of pillows and boots as interventions after informal implementation, the development of [CONDITION(S)] (2/18/21) before the presentation of the wound, pressure reduction mattress, and mobility bars for positioning. The resident propped his heels onto the footboard and box, rejected heel floating measures, and the [CONDITION(S)] was not documented in a wound, nursing notes, or reviewed as an interdisciplinary team (IDT) for further interventions proceeding wound development. The facility failed to monitor and implement interventions for Resident #226's pressure injuries and known risks for pressure injuries, and failed to comprehensively address known barriers to prevention and healing. Findings include: A concern was brought to the facility's attention on 6/7/21 at approximately 6:50 p.m. The facility was provided an opportunity to submit documentation of its response to the development of a Stage IV pressure wound for Resident #226. The facility provided documentation related to the resident's condition. However, on 6/8/21 at approximately 2:39 p.m., based on remaining concerns related to care, it was determined that the facility failed to prevent pressure injury development for Resident #226. In the first week of his admission, Resident #226's pressure injury risk was not assessed accurately/thoroughly, monitored, or treated and pressure reduction measures specific to the resident's heels were not implemented until 2/22/21. Further, while the resident had suspected inadequate meal intake of 50% or less of meals, nutritional measures to promote healing were not implemented until 2/22/21, after wound development. By this time, seven days after admission, the resident had new pressure injuries - an unstageable left heel injury, 2/19/21 which worsened to Stage 4 on 3/15/21, and a later deep tissue injury (DTI) was found to his right heel (3/1/21), the unstageable right heel wound resolved on 3/15/21. Record review, interview, and observation also revealed the facility failed to comprehensively and consistently address barriers to prevent the resident's pressure injuries. As of 6/9/21, the facility had not developed a patient-centered care plan for skin integrity/pressure areas that identified and addressed the resident's initial resistance to preventative interventions (known as early as 2/14/21). Further, a nutritional intervention acceptable to the resident was not found until 2/23/21. Modifications to the resident's wheelchair were not implemented until after a second wound had developed on 3/1/21. Finally, observations during the survey revealed the resident's heels were in a protective boot when up in a wheelchair and had wound wrappings in place while in bed but no boots were observed, heels were elevated while in bed. The resident's skin condition continued to decline; as of 3/1/21, the resident had two pressure injuries, including an unstageable right heel injury which resolved 3/15/21. As of 6/7/21, the resident had a current left heel wound measured 2.9 cm x 2.0 cm x 0.1 cm. and a progressing lower left leg/Achilles infection wound measuring 15 cm x 2.5 cm x 1.0 cm. Facility response: On 6/9/21 at 5:45 p.m., the facility submitted a finalized plan. The plan read: Resident who was identified as at-risk for development of pressure injury on initial admission Braden scale development a facility acquired left heel DTI (deep tissue injury) that progressed into Stage IV pressure injury. The facility failed to clearly show preventative measures were put into place to address the prevention and progression of the left heel pressure ulcer. An audit of Braden scale assessments was completed by DON (director of nursing)/Designee on 6/8/21 to identify residents who may have scored high risk or very high risk on the current Braden scale. Both residents identified as high risk have current preventive or treatment measures in place. Residents' records, physician orders, treatment orders reviewed, and care plans updated with current individualized interventions. Skin observations were completed by nurses for current facility residents on 6/7 through 6/9. Skin assessments were reviewed for all current residents with no new issues identified. Full house audit of residents' Braden risk evaluations was reviewed to ensure interventions in place for those identified to be at high to very high risk for skin breakdown on 6/8/21. An audit of the Braden scale assessment was completed by DON/Designee on 6/8/21 to identify any residents who may have scored high risk or very high risk on the current Braden scale. Both residents identified as high risk have current preventative or treatment measures in place. Resident records, physician orders, treatment orders reviewed, and care plans updated with current individualized interventions. Skin observations were completed by a nurse for current facility residents on 6/7 through 6/9. Beginning on 6/8/21 nursing staff education will be provided by ADON (assistant director of nursing) as they arrive for the next scheduled shift regarding head-to-toe skin observations, implemented/revision of interventions, the effectiveness of interventions, documentation, care-plan revision, notification to physician and responsible party of refusal or non-compliance with the plan of care, and policy on the refusal of cares and offering alternative choices as appropriate to be completed 6/13/21. An alternating air mattress will be provided to residents who have a pressure injury and residents who score high or very high for skin breakdown based off of Braden Risk Evaluations unless determined to be contraindicated. Re-education on quality rounds and expectations of quality rounds was completed on 6/8/21 with assigned IDT (interdisciplinary team) managers by the admission coordinator. DON/designee will review new admission evaluations and risk assessments/observations to ensure identified interventions are in place upon admission. DON/Designee will conduct quality rounds at a minimum of two times per week to ensure current implemented care plan measures are in place for individual residents. Identified issues or trends will be addressed as identified by the observer and reviewed at monitoring meetings by IDT to ensure compliance with implemented interventions. The plan will be ongoing and reviewed at the QAPI (Quality Assurance and Performance Improvement) meeting for the effectiveness of the plan. An ad hoc (when necessary) QAA (Quality Assurance Agency) meeting was held on 6/8/21 to review identified issues and quality round expectations and an action plan was developed with the input of the medical director via phone conference on 6/8/21. The plan will be reviewed at each QAPI meeting until sustained compliance is determined by IDT. Revisions will be made as needed if identified by IDT. However, the deficient practice remained. II. Professional reference A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (updated June 2021) retrieved on June 15, 2021, from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable [CONDITION(S)]. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. III. Facility policy and procedure Review of the Prevention of Pressure Injuries policy, reviewed April 2020, provided by the DON on 6/8/21 at 9:16 a.m. read in part The purpose of this procedure is to provide information regarding the identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Assess the resident on admission (within eight hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Evaluate, report, and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. IV. Resident #226 A. Resident status Resident #226, age 82, was admitted on [DATE]. According to the June 2021 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . -The CPO did not document the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/18/21 admission minimum data set (MDS) assessment documented the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. The resident displayed neither behavioral, rejecting care or wandering during the evaluation period. The resident required extensive two-person physical assistance with bed mobility and transfers, required extensive one-person physical assistance with locomotion on/off the unit, dressing, toileting, personal hygiene, and bathing, required supervised one-person assistance with eating. The resident used a wheelchair. The resident was identified as at risk for pressure injuries and a skin tear was present. A pressure-reducing device to bed, nonsurgical dressings, and applications of ointments/medications. The 3/5/21 significant change MDS assessment documented the resident had severe cognitive impairment with a brief interview for mental status score of seven out of 15. The resident rejected evaluation or care four to six days of the evaluation period. The resident required extensive two-person physical assistance with transfers, extensive one-person physical assistance with bed mobility, locomotion, dressing, toileting, bathing, and personal hygiene, required limited one-person physical assistance while walking in the room, and was independent while eating. He was not steady on his feet during transfers, while walking, or rising from sitting to standing and required staff assistance to stabilize. The resident utilized a walker and a wheelchair. The resident had two deep tissue injuries over a bony prominence being treated with pressure-reducing devices for chair and bed, nutrition/hydration interventions/ wound care, ointments/medications, and apply dressings to feet. -Neither MDS documented the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission evaluation bundle completed 2/12/21, provided by the DON on 6/8/21 at 9:16 a.m., revealed the resident was DNR, alert and oriented to three factors, had an unsteady gait, confusion, and short term memory problems, was able to understand and make self-understood. -The resident required physical assistance from staff for bed mobility, transfers, locomotion, and dressing, and was totally dependent on staff for walking/ambulating. The resident was not steady on his feet during transfers on/off the toilet, sitting to standings well as from surface to surface, and was only able to stabilize with staff assistance. Walking did not occur. The resident was provided a pressure-reducing device for bed upon admission. The Advantage 500 Mattress product specifications were provided by the DON on 6/8/21 at 6:00 p.m. It read in pertinent part, Advantage 500 Mattress provides a dual-layer of foam designed with surface sculpting to help reduce pressure and shear while creating air channels for reduced heat and moisture buildup, softer foam in heel section also helps reduce pressure and prevent heel breakdown. After the left heel wound was discovered on 2/19/21 the resident was ordered an Equalizaire Mattress: Pressure Redistribution Technology, for the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] The 2/12/21 informed consent for restraints/safety devices revealed the mobility bars were initiated to minimize the risk of injury from a fall by aiding mobility and positioning. The resident signed the consent form on 2/12/21. The admission skin assessment revealed the resident had a crescent-shaped skin tear on his left forearm. No integrity issues were documented. The Braden scale completed upon admission revealed the resident had no cognitive impairments, was rarely moist (catheter in place), walked occasionally, very limited (able to make occasional slight changes in position, unable to make frequent/significant changes independently) mobility, probable inadequate nutrition (50% of meals eaten), friction and shearing problems (requires moderate to max assistance in moving. Complete lifting without sliding against the sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance). Resident #226 was determined to be at mild risk for pressure injuries based on the admitting Braden assessment with a score of 15 out of 19. The resident was admitted with a catheter and a follow-up plan for removal. A review of Resident #226's record (set forth below) revealed the resident entered the facility on 2/12/21 with a crescent-shaped skin tear on his left forearm. After the resident requested his buttock to be examined due to discomfort on 2/19/21, the resident's heel was discovered by the wound nurse. As of 2/19/21, the resident had developed his first heel pressure injury, progressing to a stage 4 wound as of 3/15/21, the wound was healing and ongoing; followed by the right heel wound discovered by the wound physician on 3/1/21, which was documented as unstageable and resolved on 3/15/21; and an on-going [CONDITION(S)] infection wound discovered by the wound physician on 4/19/21, being followed by an orthopedic surgeon who, after examination, suggested lower left [CONDITION(S)] at the knee on 6/9/21. B. Resident observations and wound physician (WP) interview The resident was observed on 6/3/21 at 10:00 a.m. He was laying in bed slightly on his left side, without the soft boots on and under a blanket. The resident was observed on 6/7/21 at 10:15 a.m. He was lying in his room lying slightly on his right side in bed on an air mattress covered with a blanket and lowered to the floor with a mattress on the floor at the bedside. The resident was wearing his soft boots under the blankets - At 11:05 a.m. The resident was seen in his wheelchair with pressure-relieving boots on, being wheeled into the television room for a group activity. The WP was observed and interviewed during wound care to the left lower leg and heel on 6/3/21 at 12:00 p.m. The WP was examining and [MEDICATION(S)] the wound to the lower left leg/Achilles. After cleaning the wound with saline, a strong odor was still present during wound care. The left lower leg wound over the Achilles tendon was red with exposed muscle tissue and tendon and visual necrotic tissue. The wound measured 15 cm x 2.5 cm x 1.0 cm. As the WP was removing necrotic tissue the resident began pulling his leg away with a grimace on his face. The WP paused treatment and injected the skin around the wound with additional [MEDICATION(S)]. He resumed treatment briefly after injecting the resident. The resident continued to pull away while the WP was providing treatment and grimacing on his face. The WP ceased necrotic tissue removal, packed the interior of the wound with gauze (dakine packing), covered it with a clean dressing (Cipro antibiotic covering), and wrapped it in [MEDICATION(S)]. The resident's left heel wound was intact and measured 2.9 cm x 2.0 cm x 0.1 cm and 100% granulated tissue. The wound was cleaned and covered in a dressing. The WP said his first examination of the resident's heel wound was on 3/1/21. He said he discovered the resident's right heel wound during the appointment, as well. He said the resident acquired the left heel wound shortly after admission and was identified by the wound care specialist (WCS). The WP said when the lower left leg/Achilles wound first presented on 4/19/21 he thought it would connect to the heel wound, believing it to be one wound. He said after two weeks of the wounds being separate he classified them again as separate wounds. He said an x-ray was taken of the resident's leg and revealed an [CONDITION(S)] infection. He said the muscle and tendon of the lower left leg/Achilles were necrotizing and the dead tissue was spreading up the resident's leg. He said the resident was scheduled for a follow-up with an outside orthopedic surgeon for the wound and more intensive surgical debridement for the lower-left leg wound. He said the left heel wound and lower left leg/Achilles wound were improving. He said the lower left leg/Achilles wound was unavoidable due to infection. He said the resident had a peripheral vascular disease which interfered with the healing process. He said he was not aware of measures the facility put in place or what the resident was doing at the time he acquired the wound, but said the wound was avoidable if the facility had implemented offloading measures before the development of the blister. The WP did not know the origin of the resident's [CONDITION(S)]. C. Resident representative interview The resident representative was interviewed on 6/8/21 at 11:34 a.m. He said he attended almost all of the resident's appointments. He said the facility was following the resident's wounds closely and had involved outside surgeons and physicians for treatment and consultations. He said the orthopedic surgeon built a brace for the resident's leg for protection and stabilization and the wound care physician was treating the wound weekly. He said he received a call from the facility about the [CONDITION(S)] the resident had experienced on 2/18/19, but the staff member did not mention any problems regarding the resident's shoes causing any issues. He said the resident was experiencing [CONDITION(S)] before admission and while in the hospital. He said the podiatry appointment and issues with shoes not fitting were not communicated to him. D. Record review The February 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Orders for the left heel wound treatment and offloading heels due to a DTI and checking the air mattress for proper functioning were added on 2/19/21. The 48-hour Meet and Greet Care Conference Review completed 2/12/21, was provided by the DON on 6/9/21 at 4:00 p.m. The baseline care plan included in the care conference documented the residents nursing needs as requiring assistance for transfers, bed mobility, locomotion of wheelchair and toileting, dependent of staff for walking, independent while eating, the resident can voice concerns and communicate needs effectively and was alert and oriented to three factors. The only skin concern was the crescent-shaped skin tear to the resident's left forearm. The social service concerns documented the resident was at the facility for a short-term stay after suffering a fall at home. Resident was to return home. The resident is DNR and has good family support. Dietary concerns documented the resident was on a regular diet and fluids, no known allergies, no supplementation at this time, full dentures, intake is fair and eats independently, speech therapy (ST) evaluations ordered, has current dysphagia. Therapy services concerns documented current ST, occupational therapy (OT), and physical therapy (PT) services to increase resident activity of daily living (ADLs) and transfer strength and gait. Nursing notes from 2/13/21, 2/14/21, 2/16/21, and 2/17/21 documented the resident was taking medications, able to make some needs known, confused at times, skin is warm, dry, and intact, and had increased weakness requiring one to two-person physical assistance with transfers. The resident was adjusting well and had a call light within reach. A nursing note from 2/14/21 documented the resident needed reminding to use the call light for assistance. The updated care plan, dated 2/15/21, documented the resident's risk for skin breakdown related to fracture and decreased mobility. Interventions documented included check and change upon awakening, before and after meals, at bedtime, and as needed, Provide incontinence care after each incontinent episode and as needed, complete weekly skin observations, and PT/OT as ordered (added 2/15/21); - Barrier cream applied and a cushion placed in wheelchair (added 2/19/21); - Maintenance to remove the anti-rollback system from residents wheelchair, alternating air mattress, bunny boots (encourage use), PT/OT, multivitamin, and supplements for wound healing (2/22/21); - Off-loading boots and foot pedals for wheelchair (added 3/2/21); - Resident educated to be cautious of his hands and upper extremities in an attempt to avoid bumping himself, causing skin injury (3/9/21). There was no mention of floating the resident ' s heels while in bed or in a wheelchair. A physician encounter note dated 2/15/21 and 2/16/21 documented the resident was admitted to the facility after a fall at home resulting in a pelvic fracture. The resident reported having increased issues walking while at home. Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . While in the hospital the resident was also diagnosed with [CONDITION(S)], [CONDITION(S)], and pneumonia. He recovered in the hospital and was referred to an orthopedic surgeon for follow-up. The orthopedic surgeon recommended weight-bearing as tolerated to the lower left extremity until orthopedic follow-up. Due to deconditioning during hospital stay, the resident should be followed by PT and OT. Orthopedic and urology follow-up scheduled. The resident had no peripheral [CONDITION(S)] and skin was dry, intact, with good turgor, with no redness or cyanosis (blueness). The resident was seated in his recliner at bedside without apparent distress. OT and PT assessments dated 2/15/21 documented the resident could weight bear as tolerated, ADL training had begun and the resident was participating, gait training began, and education about the safe placement of limbs was provided to the resident. There was no follow up documentation that the resident understood the education or demonstrated safe placement of limbs. The assessments did not document if the resident understood or could demonstrate said positioning. A 2/15/21-2/26/21 Quality Rounds checklist was provided by the DON on 6/8/21 at 9:16 a.m. It documented the resident's room number and the date on each form. -On 2/15/21 and 2/22/21 documentation revealed that the resident had appropriate appliances, and in the comment column bunny boots were documented. The form did not document if the boots were on or not. -On 2/16/21 the Quality rounds documented the resident was not wearing bunny boots while in bed. - On 2/17/21, 2/18/21, 2/19/21, 2/20/21, 2/21/21, 2/23/21, 2/24/21, 2/25/21, and 2/26/21 a checkmark documented the appropriate appliances were present but did not specify which appliances. The dietary profile and assessment were completed 2/15/21, documented the resident was on a regular diet with mechanical soft texture, no fluid restrictions, regular portion sizes, fair appetite, used no assistive devices, and independently fed self. Documented the resident's use of laxatives and vitamins, nutritional risk factors included pressure ulcer, difficulty swallowing (dysphagia diagnosis), altered diet texture, and recent fracture. The resident was screened for new admission, current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Will monitor weights and intakes to assess the need for nutritional interventions. Labs and medications reviewed. A skilled progress note dated 2/16/21 documented the resident's skin was warm, dry, and intact, able to make some needs known, continues to be confused at times, and has increased weakness requiring one to two physical assistance from staff with transfers and repositioning. The resident needs continued supervision with ADLs due to fall risk. A 2/17/21 skin observation form revealed the resident only had a skin tear to the left forearm. A skilled progress note dated 2/17/21 documented the resident was to receive PT and OT services for gait and ADL training four times a week. The resident was resting in bed with his eyes closed, able to make some needs known, no complaints of pain or discomfort, and was compliant with medications. The resident had increased weakness, requiring one to two physical assistance from staff with transfers and repositioning. The resident needs continued supervision with ADLs due to fall risk. A 2/18/21 OT note documented the resident's right ankle was swollen and unable to donn shoe but could donn non-skid socks. Reported swelling to nursing staff. Nursing notes between 2/12/21-2/19/21 failed to document the resident had any skin concerns/breakdown/[CONDITION(S)]/blistering/redness. <br[TRUNCATE

Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents, affecting three (#35, #11, and #9) of 32 sample residents. Specifically: -The facility failed to maintain an effective system to prevent resident elopement. Resident #35 and #11 were known to be at risk to elope. Each resident wore a wander guard which triggered an alarm and locked the door if the residents attempted to exit the facility. However, Resident #35's wander guard, which sounded on [DATE], did not prevent her from exiting the building. Observations and interviews revealed the facility's technological security system and staff practice created an ineffective resident security system. Staff response to and monitoring of alarms was inadequate. And, review of the functioning of the facility's wander guard system revealed both the alarm and the locked door could be bypassed in four exit areas. These failures created a situation of immediate jeopardy with the potential for serious harm for the residents known to be at risk to elope. -The facility also failed to implement care planned measure to maintain Resident #9's safety from falls. Findings include: RESIDENT SECURITY SYSTEM TO MANAGE ELOPEMENT RISK I. Imposition of immediate jeopardy On [DATE] at 11:15 a.m., the nursing home administrator (NHA) was informed the failure of the facility's resident security system represented a systemic failure to effectively manage elopement risks and this created a situation with the potential for serious resident harm for Residents #35 and #11 who were known to be at risk to elope. II. Facility response and removal of the immediate jeopardy A. On [DATE] at 3:20 p.m., the facility submitted a final (5th) version of a plan to remove the immediate jeopardy situation. The plan included the (named) wander guard/door alarm company was contacted and sent out a technician to correct the bypass issues with the door alarms. During the door correction, the residents with a wander guards were placed in direct line of vision with trained staff members until the doors were fixed. All staff were required to complete training on wander/elopement alarms and door alarms as well as line of sight monitoring for the identified residents prior to clocking in for their assigned shift. On [DATE] at 1:26 p.m. the staff development coordinator/assistant director of nursing (SDC/ADON) presented the training for the staff titled, Elopement and Wander guards-Staff Responsibilities. The training identified how the staff needed to respond to door alarms, how to redirect an individual with a wander guard away from an alarming door, to check the door and immediate proximity to ensure the safety of all residents who may have exited through the door, and placement of a wander guard alarm on On [DATE] at 1:30 p.m. the NHA provided a form outlining the implementation of elopement drill audits to test the effectiveness of the door alarm and the staff's response. The frequency of the drills was every shift for seven days then once a week per shift for four weeks. The data collected would be taken back to the QAPI (quality assurance and performance improvement) meeting for evaluation of effectiveness and potential modifications through analysis of the data collected to ensure a safe environment for all individuals to include identified residents with a wander guard alarm. The NHA also provided an elopement risk tool to be utilized upon admission, quarterly, and with a significant change. The wander guard transmitter verification of effectiveness would be conducted weekly using the tester per manufacturer guidelines. On [DATE] at 3:20 p.m. the NHA provided a revised edition of the elopement protocol that included the incorporation of the use of wander guards, including how the staff responds to a door alarm (see above training). The wander guard system identified as Code Alert Model 70 was connected to the backup generator in case of a power outage. The system had enclosed batteries and an expiration date identified on the device. The facility explained the device is already on when received, and is discarded upon expiration. The facility would ensure the effectiveness of the device weekly with the testers located at each nurses' station (there are two nurses' stations and two testers). The location of the wander guard on the resident will be documented in the resident record and verification of location will be completed by the assigned nurse on the Medication Administration Record [REDACTED]. B. The NHA was notified on [DATE] at 3:16 p.m. that the situation of immediate jeopardy for serious harm was removed as observations revealed the doors could no longer be bypassed and staff was receiving training on how to respond to an elopement. However, deficient practice remained at a D level. III. Facility characteristics A. Layout of the building The building had four hallways. The first hallway when entering the facility from the front sliding doors or the adjacent handicap entrance contained the social services office and the therapy department. This was the only hallway that led to the front of the building as well as to the elevators that allowed access to the assisted living residence attached to the building. This hallway ended at a junction with a nurses' station and the beginning of P hall which ran south from the junction and ended with an exit. At the junction, the first hallway became B hall, which ran east and west. B hall ended at another junction with a nurses' station. At this junction, C hall ran south to an exit door and D hall (previously B hall) ran east west and ended at an exit. The entrance sliding doors and the doors at the end of each hallway except B hall (which ended at a nurses' station) were secured with an alarm. There also was an alarm on the wall outside the therapy department, approximately 40 feet from the front sliding doors. B. Technological security system The facility utilized wander guard transmitters as well as a door alarms for resident security. The wander guard transmitters were each stamped with a warranty expiration date of 1.5 years. Per manufacturer instructions, the operation of the transmitters was to be tested weekly following four mandatory steps, including: test the device using the transmitter tester - never take a resident to a door to test the device; visually inspect the transmitter for damage or loose parts; verify that the warranty expiration date stamped on the transmitter has not expired; and keep records of test and transmitter inspection. The instructions for monitoring a resident in a wheelchair read to attach the transmitter to the seat or the back of the chair. The transmitter should not be placed directly on the metal of the wheelchair as it can interfere with the transmitter's signal. The door alarm could be set on three different alarm options. Review of the user guide revealed two of these options included: -Staff Bypass Mode: A facility may need to configure the Delayed Egress Exit Alarm Controller to use Staff Bypass Mode. Staff Bypass Mode enables the door to remain unlocked for a preset period of time. During this time, anyone can pass through the secured door, including patients wearing Transmitters, without an alarm. -Visitor Bypass Mode: Visitor Bypass Mode allows people who are not wearing Transmitters to exit through the secured door. However, when a patient wearing a transmitter attempts to exit through the door simultaneously, an alarm occurs. C. Facility wander guard and elopement policy and practice The NHA was interviewed on [DATE] at 10:50 a.m. She said the facility did not have a wander guard policy, but instead utilized an elopement risk tool. The score from the tool would determine further assessment that could include the use of a wander guard. She said the use of a wander guard was assessed quarterly by the interdisciplinary team (IDT). The facility had an Elopement Protocol, however, that covered use of the elopement risk tool and potential use of a wander guard device, missing person procedures, door alarm procedures and elopement drills. Door alarm procedures included the following: Staff would immediately respond to determine the cause of the sounding alarm; if cause of the alarm is not immediately identified, staff were to conduct a visual search of the area, including the outside perimeter; if cause of alarm is still undetermined, staff would verify location of resident with wander guard device in place; if residents with wander guard are located, further search was no longer indicated; if resident with wander guard cannot be located, initiate missing person procedure. IV. Evidence of facility's need for an effective resident security system. A. Resident #35 and #11 1. Resident #35 - known elopement risk and successful elopement [DATE] Resident #35, age 91, was initially admitted on [DATE]. Her most recent admission was on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the [DATE] minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. No mood or behavior symptoms were noted. She required extensive assistance for bed mobility, transfers, grooming and toilet use. According to observations (see below) and staff interviews, the resident utilized a wheelchair for mobility and was able to propel herself in the wheelchair. a. Record review revealed the resident was known to be at risk to elope and the facility had developed interventions to address this risk. A safety device consent for the use of a wander guard was signed [DATE]. An exit seeking care plan was initiated [DATE] (revised [DATE]) that identified the resident as being at risk for elopement related to recent exit seeking behaviors and poor cognition related to dementia. The goal was for the resident's elopement risk to be minimized with interventions through the next review. Interventions, all initiated [DATE], included documenting the frequency of elopement attempts each shift, encouraging participation in activities, redirection, checking the placement of the wander guard and periodic review for continued use of the wander guard. An elopement care plan was initiated [DATE] (revised [DATE]) that identified the resident as being an elopement risk, disoriented to place, impaired safety awareness and frequently wanting to go to her car or requesting to leave to get her family. The goal was for the resident not to leave the facility unattended through the next review. Interventions included distracting the resident from wandering by offering pleasant diversions, identifying the pattern in the resident's wandering, redirecting and orienting as needed and placing a wander guard. An [DATE] elopement risk tool revealed the resident continued with exit seeking behaviors and propelled herself in her wheelchair around the facility. Review of the Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. b. Staff interviews confirmed the resident was at risk to elope Certified nurse aide (CNA) #3 was interviewed on [DATE] at 10:56 a.m. She said the resident was frequently wandering up and down the halls in the facility. She said the resident was frequently going down D and C hall and attempting to go out the exit doors. CNA #8 was interviewed on [DATE] at 11:15 p.m. She said the resident liked to go up and down the hallways in the facility. She said the staff always catch the right before she is going out the exit doors. She said the resident will also go in and out of other resident rooms, and staff is frequently redirecting her. The restorative CNA (RCNA) was interviewed on [DATE] at 10:59 a.m. She said the resident puts her clothes on her lap and then heads for the exit door. She said the staff do attempt to redirect her, but it can be difficult when the resident wants to leave the building. The life enrichment director (LE#1) was interviewed on [DATE] at 11:02 a.m. He said the resident wanders in the facility and she is frequently looking for her parents. He said the staff attempt to redirect the resident, and that will occasionally work. Licensed practical nurse (LPN) #4 was interviewed on [DATE] at 11:05 a.m. She said there are two residents in the facility that wandered, Resident #11 and #35. She said the staff in the facility attempt to keep an eye on both of these residents and try to redirect them when they are exit seeking. LPN #3 was interviewed on [DATE] at 11:10 a.m. She said resident #35 frequently goes up and down the hallways looking for her family and her car. She said the staff had to frequently redirect the resident. c. Observation Resident #35 was observed on [DATE] at 3:41 p.m. going in and out of other resident rooms looking for the show. An unidentified staff member assisted the resident back to her room. d. Resident #35's elopement - Facility response Review of the [DATE] nurse progress notes revealed the resident exited one of the doors located at the front of building. Two staff members, with an office located near the front doors, were alerted by a staff member's daughter that the resident was outside the building and had fallen. -The resident was located outside the front door, lying on her left side in a fetal position in front of her wheelchair. The resident had a large amount of bleeding from an abrasion to her right forehead. The resident's right shoulder was noted to be swollen with bruising. The resident had decreased range of motion as well as pain in the right shoulder. The resident was transported to the hospital due to the pain and swelling in her right shoulder. -After the resident's hospitalization , she was discharged to a hospice house for two days. She was readmitted to the facility on [DATE]. Review of the [DATE] interdisciplinary team (IDT) review of the resident's fall revealed the root cause of the resident's fall was poor safety awareness related to a history of falls with injury. The resident had impaired cognition, mobility and weakness which caused her to wander throughout the building. The recommendations of the IDT were to educate visitors through the use of signs to not allow residents outside the building without first checking with staff. -According to IDT review, the resident's wander guard was on and did activate the alarm system. -According to the IDT review, it was determined that a family member of another resident who was discharging at the time of the incident opened the door, allowing the resident access to the outer lobby door. Visitor opened the outer door utilizing the handicap access button. The NHA was interviewed on [DATE] at 10:55 a.m. She said she was working the day of the resident's fall. She said the fall happened during the week in the morning around 11 a.m. She said she was in a meeting on the second floor in the conference room. The NHA said she remembered hearing one of the wander guard alarms going off, but could not recall if it was the front door alarm or the alarm located near the therapy department. 2. Resident #11 - known risk for elopement Resident #11, age 96, was admitted on [DATE]. According to the (MONTH) (YEAR) computerized physician orders [REDACTED]. According to the [DATE] MDS assessment, the resident had severe cognitive impairment with a BIMS score of two out of 15. No mood or behavior symptoms were noted. She required extensive assistance for bed mobility, transfers, grooming and toilet use. According to observations and staff interview (see below), the resident utilized a wheelchair for mobility. a. Record review revealed the resident was known to be at risk to elope and the facility had developed interventions to address this risk. The resident's care plan, initiated [DATE] (revised [DATE]), identified ADL risk for elopement due to dementia and a history of exit seeking behaviors. Interventions, all initiated [DATE], included documentation of elopement attempts, redirection, and the use of a wander guard. A consent for a wander guard was signed ,[DATE], and an IDT team meeting on [DATE] identified the resident's continuing need for the wander guard. Review of the MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The (MONTH) (YEAR) MAR (,[DATE] - [DATE]) documented the resident had no attempts to elope. b. Staff confirmed the resident was at risk for elopement CNA #12 was interviewed on [DATE] at 8:20 a.m. She said the resident would propel herself back and forth in the halls to the exit doors. She said the resident had set off the door alarm a few times over the last couple of months. She said she reports the resident's actions to the nurse on duty. She explained when the staff would see the resident near the door or if the resident set off the door alarm, the staff would approach and redirect her. c. Observation Resident #11 was observed in the dining room on [DATE] at 11:00 a.m. and roaming up and down both the C hall and the D hall in her wheelchair after lunch at 1:25 p.m. V. Facility failure to maintain an effective resident security system through use of technology and staff A. Technological failures 1. Observations Observations revealed the security system worked inconsistently and could be by passed. On [DATE] beginning at 7:34 a.m. the plant operation manager (POM) demonstrated the facility's wander guard system on the following doors in the facility: -The sliding glass door located at the front of the facility would not alarm after three attempts using a wander guard. The POM said the door should alarm when a wander guard comes near the door and the door should lock; however, the POM said the sliding glass door did not lock. -The handicap accessible door next to the sliding glass door at the front of the facility locked when the wander guard came in proximity of the door, but on two occasions, the alarm did not sound. When the handicap button on the wall (located both outside and inside the building) was pushed, the door did not alarm or lock. - The door located on P hall south did not lock after three attempts, but did alarm. The door also had a green push to exit button located near the code alarm box. The POM said the green button allowed staff and families to exit from the door without triggering the alarm and locking the door. -The door located on C hall south also had a green push to exit button. The button served the same purpose as the P hall button, and when pushed, the alarm was deactivated. The POM demonstrated with a wander guard that when the green button was pushed, an individual with a wander guard would not cause the alarm to sound or the door to lock. 2. POM interview The POM was interviewed on [DATE] at 7:47 a.m. He said the green push to exit button as well as the handicap button on the front door, defeated the purpose of the resident security system. He said he checked the functioning of the wander guard doors on a weekly basis using one of two testers that were available in the facility. The POM said he kept a tester in his office and the other tester was at one of the nurses' stations; he was unsure which one. 3. Security system representative interview The representative from resident security system was interviewed on [DATE] at 2:47 p.m. He said there was a four foot radius around all of the alarms. When a resident with a wander guard came into that four foot radius, the door would alarm and several of the door were set-up to lock. He said the only doors that would not lock were the front handicap accessible door and the door at the end of C hall south and P hall south. He said previously (prior to the facility's notification of immediate jeopardy) the handicap button on the front door handicap entry and the green push to exit button on the exit doors at the end of C and P hall had bypass buttons and were set up in Staff Bypass Mode (see above). When in that mode, anyone, including a resident with a wander guard, could walk out the doors without the door alarming. He stated the alarm outside the therapy department was the facility's first line of defense if a resident was wandering toward to the front door area. He stated the second line of defense were the alarms on the front doors of the building. 4. Record review See facility investigation following Resident #35's elopement on [DATE]. There was no evidence door alarms were checked following the incident. B. Staff failures 1. Failure of staff to properly place wander guards Expectation: See above instructions for monitoring a resident in a wheelchair; the instructions read to attach the transmitter to the seat or the back of the chair and included a directive that the transmitter should not be placed directly on the metal of the wheelchair as it can interfere with the transmitter's signal. Observations: Resident #35 was observed on [DATE] at 2:34 p.m. in her room, in her wheelchair, pulling clothing from her closet. Her wander guard was affixed to the metal part of her wheelchair. Resident #11 was observed in the dining room on [DATE] at 11:00 a.m. Her wander guard was affixed to the metal part of her wheelchair. Resident #35 was observed in the dining room on [DATE] at 12:10 p.m. The wander guard was affixed to the metal part of her wheelchair. Resident #35 was observed again on [DATE] at 3:09 p.m. in her room in her wheelchair, after the facility had been notified of the immediate jeopardy situation. The resident was observed pulling clothes out of her closet. The wander guard was affixed to the resident's left wrist. 2. Failure to properly check wander guard Expectation: See above instruction for checking the functionality of the wander guard; these instruction read to use the transmitter tester; never take a resident to a door to test the wander guard. Interviews: LPN #8 was interviewed on [DATE] at 7:52 a.m. She said each resident with a wander guard had an area on the MAR for the nurse assigned to check placement. She said resident #11 had her wander guard on her chair. She said she checked the wander guard transmitter daily by taking the resident in the wheelchair to a door. LPN #7 was interviewed on [DATE] at 4:22 p.m. She said resident #35 was her resident that evening. When checking the resident's wander guard to make sure it is functioning, she takes the resident to the door and makes sure the alarm goes off. 3. Failure of staff to respond to alarms Expectation: See elopement protocol above on door alarms which read staff would immediately respond to determine the cause of the sounding alarm; if cause of the alarm is not immediately identified, staff will conduct a visual search of the area, including the outside perimeter; if cause of alarm is still undetermined, staff would verify location of residents with wander guard device in place; if residents with wander guard are located, further search is no longer indicated; of resident with wander guard cannot be located, initiate missing person procedure. CNA #12 was interviewed on [DATE] at 8:20 a.m. She said the residents cannot get outside because of all the alarms. She said when a door alarm sounds, the staff go to the alarm panel (at the nurses' station at the junction of C and D hall) to see which door alarmed. The staff would go to the door that alarmed, search the area for the residents with a wander guard and turn off the alarm. LPN #8 was interviewed on [DATE] at 7:52 a.m. She said when a door alarm sounds, all staff were to stop what they are doing, as long as it does not put anyone in danger, to respond to the alarm. LPN #4 was interviewed on [DATE] at 7:53 a.m. She said wander guards and families are the most common causes for the alarms to go off. She said when that happens, all staff need to respond to ensure all the residents are safe. Observations: On [DATE] at 8:40 a.m. the C Hall exit door alarm sounded. Immediately, CNA #8 responded to the door, turned off the alarm, opened the door, and searched the immediate proximity. She did not verify the location of the two residents with wander guards . On [DATE] at 8:53 a.m. the C Hall exit door alarm sounded again. CNA #1 was in a doorway of a resident room on the hallway, looking toward the alarming door. She did not respond to the alarm. Licensed practical nurse (LPN) #4 was midway down the hall at the medication cart. She, too, did not respond. After 45 seconds of the alarm sounding, CNA #6 came from the beginning of the hall where the nurses' station was located. She silenced the alarm and searched the area for residents. Interview: The ADON was interviewed on [DATE] at 10:23 a.m. She said she had been training all staff to respond to all alarms for the safety of all residents, however, the facility did not have any specific training for nurses. Training for CNAs was on the skills checklist, however, it was completed as part of the walk through. She said there was no specific lesson plan, but said one would be developed one immediately. The DON was interviewed on [DATE] at 1:25 p.m. The DON said the receptionist and each unit needed to know which resident was an elopement risk; she said the receptionist had an elopement book and each nurses' station had an elopement book. However, review of the elopement books at the nurses' station revealed each binder only included the name of resident at risk for elopement who was assigned to that particular station. FALL PREVENTION I. Facility Policy and Procedure The Falling Star policy and procedure, updated [DATE], and provided by the DON read, in part, When staff passes by the room of an identified frequent faller they will be more observant of what the identified resident is doing and attempt to anticipate his or her needs. II. Resident #9 A. Resident status Resident #9, age 84, was admitted [DATE]. According to the (MONTH) (YEAR) CPO, [DIAGNOSES REDACTED]. The [DATE] MDS assessment revealed the resident was cognitively impaired with memory difficulties and periods of disorientation. She was not always able to make her wants and needs known. She required extensive to total assistance of two people with her activities of daily living (ADLs). She was admitted to the facility under hospice care. She was always incontinent of bowel and bladder and had an unstageable pressure wound upon admission. She had a history of [REDACTED]. B. Record review 1. Care plan The comprehensive care plan, revised [DATE], revealed the resident was at risk for falls related to a history of falls with injury (fracture and subdural hematoma), hypertension (HTN), weakness and impaired cognition. She was post hospitalization for falling and subsequent subdural hematoma. The resident would hang her legs over edge of bed and scoot herself off the bed. The goal was for her fall risk to be minimized with interventions. The interventions included: - Falling star program (Initiated [DATE]) - Apply hipsters (Initiated [DATE]) - Mattress (fall mat) at bedside while in bed to allow her more space to move around. (Initiated [DATE]) - Resident needs a safe environment free from spills and/or clutter, adequate, glare-free light, the bed in low position and personal items within reach. (Revised [DATE]) - Frequent checks for bed placement. (Initiated [DATE]) - Low bed in lowest position to allow closer proximity to floor. (Initiated [DATE]) C. Resident observations The resident was observed during incontinence care on [DATE] at 10:11 a.m. The resident did not have hipsters on and the staff did not offer or encourage the resident to wear hipsters or attempt to place them on the resident. The resident was observed lying in bed with the head of the bed elevated on [DATE] at 12:19 p.m. The bedside table was in front of the resident with her lunch on it. The bed was not in the lowest position to the floor and the fall mat was not on the floor beside the bed. There were no staff in the room supervising the resident with her meal. Through continuous observation, multiple staff members, including the social service director, CNAs and the NHA were observed to pass by the room without looking into the room to ensure safe positioning of the resident. At 12:53 p.m., CNA #25 entered the resident ' s room and took the lunch tray from the room. The bed remained at an elevated height and the fall mat was not placed on the floor beside the bed after the meal was removed. At 1:23 p.m., CNA #25 entered the room and assisted the resident to reposition. Upon leaving the room, the bed was placed in its lowest position and the fall mat was placed beside the bed. The resident was observed sitting up in the bed on [DATE] at 8:35 a.m. The bedside table was in front of the resident with her breakfast tray on it. The bed was not in the lowest position to the floor and the fall mat was not on the floor beside the bed. Staff did not stay in the room to supervise her. D. Staff Interviews CNA #23 was interviewed on [DATE] at 8:45 a.m. She said she had been working at the facility for one month. She said the staff communicate fall interventions to each other during report at the beginning of each shift. She said she did not know what the falling star program was. CNA #5 was interviewed on [DATE] at 9:00 a.m. She said the fall interventions could be found on the resident ' s kardex in the computer. She said the resident ' s fall interventions included to keep the bed in its lowest position, place a fall mat beside the bed and to check on her frequently. She said the bed could be left in a higher position while she ate, but the fall mat should be placed on the floor. RN #2 was interviewed on [DATE] at 9:30 a.m. She said the fall interventions for the resident included frequent checks, keeping the bed in the lowest position to the floor and to place a fall mat beside the bed. She said during meals, the staff should stay with the resident if the bed could not be in the lowest position. The DON was interviewed on [DATE] at 10:30 a.m. She said the staff should follow the fall interventions identified on the care plan at all times. She said the staff should have offered and encouraged the resident to wear the hipsters and all staff should look in on the resident as they pass by the room to ensure safety. She said the bed should be kept in its lowest position to the floor with the mat beside the bed even when the resident is eating in bed.

Based on record review, observation and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for two (#2 and #9) of nine sample residents, the facility failed to ensure an environment free of accident hazards, and failed to provide adequate supervision to prevent potential accidents. For resident #2, the facility failed to provide safe transport in the facility van to prevent injury, and for resident #9, the facility failed to provide adequate supervision for a vulnerable resident isolated during meal time. Resident #2, according to the facility admission record, was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's most current quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident used a hearing aid and had moderate difficulty hearing, her speech was unclear; she sometimes understood simple, direct communication. Her vision was adequate. Facility staff assessed the resident as having long- and short-term memory problems. The resident was easily annoyed, short tempered, and had difficulty concentrating, such as reading a paper, or watching television. At times, the resident rejected care. She was totally dependent on the physical assistance of two staff for transfer, toilet use, and bathing. She needed extensive physical assistance of two staff for dressing and personal hygiene. She had impairment of range of motion for both upper extremities. She did not walk. She used a wheelchair for mobility. She needed extensive assistance of one staff for transport on and off the resident's unit. The resident's Interdisciplinary Team (IDT) Care Plan revealed an identified problem of potential for injury related to cognitive impairment, poor safety awareness, weakness, inability to make most needs known, impaired vision, impaired mobility, start date 9/11/12. Approaches included provide appropriate level of assistance to promote safety. The IDT care plan assessed a risk for developing contractures secondary to decreased active range of motion in both hands; admitted with contractures of both hands, start date 9/11/12. Nurses' notes, dated 1/21/13 at 1:15 p.m., revealed the facility received a call from the van driver who was driving the resident to a dental appointment. When he braked at a red light, the resident fell out of the wheelchair to her right side. The Certified Nurse Aid (CNA) was also in the van in the front seat. The driver pulled over, and they both lifted the resident into the wheelchair. The resident has a hematoma over the right ear and a small laceration of the right eye, and complained of pain in the left knee. The resident's family member was driving right behind the van and pulled over behind the van. They opted to take the resident to the emergency room . The van driver took the resident to the emergency room and the CNA stayed with her. The CNA called to report the resident was being admitted to the hospital with [REDACTED]. NHA notified of occurrence by phone. Review of the facility investigation of the incident and occurrence report revealed the following: On 1/21/13 at approximately 1:00 p.m., the resident was being taken to a dental appointment when the facility van driver stopped abruptly at a red light. The van is a three passenger handicap van. The van driver was suspended during the investigation. The van driver stated that he was going south on Pueblo boulevard. There was another vehicle in front of him. The vehicle in front of him braked for a red light and he had to brake hard to avoid hitting the car in front of him. The CNA in the van did not see the speedometer when the van driver was driving, but stated she thought he was going fast. The resident's daughter who was following the facility van stated that she was driving 60-65 miles per hour (mph) to keep up with the van, though the speed limit was 55 mph. The wheelchair was secured with safety straps and did not fall over with the resident. The van driver stated that he had fastened the safety belt across the resident. The CNA could not remember if the safety belt was across the resident. She was sure that the safety belts holding the wheelchair in place were in use as the wheelchair did not tip over with the resident. The van driver immediately radioed the facility and the resident was taken to the emergency department. The facility conducted six client interviews, and revealed the following in pertinent part: Resident stated the van driver at times gets a little speedy. Resident stated the van driver was a very good driver, but complained once about other appointments. The facility conducted six staff interviews, and revealed the following in pertinent part: The CNA who accompanied the resident stated she was seated in the front of the van as there is no room for someone to be seated in the back when a wheelchair is in place. She stated that when she has gone with the van driver at other times, "He could slow down. There is no need to rush." Another CNA stated, "He drives like a maniac. Residents complain a lot. They tell him to please slow down. When he drives through turns, it is really fast and the residents sway in their wheelchairs. He uses safety straps. He slams on the brakes. I've had to reach back to steady residents when they are swaying with his driving." Another CNA stated, "He drives a little too fast. He always seems panicky, like in a rush, like he's going to be late. I've seen him strap everybody in. I've heard residents say he drives too fast." Another CNA stated, "He gets in too big a hurry. He drives too fast. I tell him to slow down. He always belts wheelchairs into place, but not sure about safety belts with residents in wheelchairs. It seems like some days he's so overwhelmed." Another CNA stated, "He drives a little fast, that was one time." Another CNA stated, "He speeds while driving. He seems stressed, like trying to get everything done at once." The facility conducted five family interviews, and revealed the following in pertinent part: One resident's son stated that his father stated the van driver drives too fast, however when the resident was interviewed separately, he did not voice any issues. Review of resident council minutes for 1/13, 2/13 and 3/13 revealed on 3/19/13, the Director of Maintenance (DM) announced a new driver was hired and would be starting soon. There was no documentation of discussion of safety issues or a request for resident input for the safety of transportation by the facility. Observation: On 4/9/13 at 12:30 p.m., a facility van was observed. The van driver stated he was starting work today as a van driver. A maintenance staff was also present. He stated he was helping with the new van driver. The floor of the back of the van had straps to secure a wheelchair to the floor, and a seat belt that fastened diagonally across the full back seat. There would be no room for staff to sit in the back seat close to the resident. The fastenings were in working order. The Maintenance staff stated this van was due to be replaced. Interviews: On 4/10/13 at 8:15 a.m., the van driver stated this was his second day on the job. He stated he had been shown safe use of the van. At 11:40 a.m., the DM, a Maintenance Staff, the Director of Nursing (DON), and the Nursing Home Administrator (NHA) were interviewed. The Maintenance staff stated he had been providing transportation for residents off and on since 2006, and had been recently doing transportation for three months straight. The NHA stated the van driver involved in the occurrence was dismissed and had not been hired back to the facility in any capacity. They had been working on a corporate van safety policy and procedure. The DM stated that as part of the investigation, they did a test transport with staff and determined that the seat belt could not have been fastened, and it was highly unlikely, especially with this resident, that a resident could self-release the seat belt. They provided a wheelchair tie down inservice and training video to the van drivers. Two people made the transportation van schedule, one from the long term care side and one from the assisted living side. He reviewed the schedule the night before and added another driver if there were scheduling conflicts. He stated he was surprised at the resident interviews, that residents did not report that they did not feel safe. One resident told him when they did interviews that she was afraid when the former driver took her to appointments. When he asked why she did not complain to him, she stated she was afraid to. He had asked informally how things were going when he transported residents, and they liked the current driver, stated he played classical music. He stated he had not asked formally if the residents felt safe currently during transport, and agreed that residents and staff had not volunteered any of the information prior to interviews for the previous driver. The transportation safety issue had not been brought up in Resident Council, other than the information that a new driver had been hired. He stated no inservice had been provided for the facility staff who accompany residents to appointments, but agreed that a second pair of trained eyes to make sure the seat belt was fastened would be a good idea. The NHA stated there had been no formal follow up with the residents regarding the current van driver, and nothing was currently in place for follow up for the van driver just hired. There was no education provided to facility nursing staff who accompany the residents to appointments regarding safe transport, but agreed that would be good to provide. There was not always an accompanying staff person. Nursing made the determination if the resident needed staff accompaniment on appointments. Resident #9, according to the facility admission record was admitted [DATE], with [DIAGNOSES REDACTED]. The resident's most current MDS, dated [DATE], revealed the resident required extensive physical assistance of one staff for bed mobility, transfer, dressing, eating, toileting, hygiene, and total physical assistance for bathing. The resident had a Brief Interview for Mental Status score of 3, indicating significant memory impairment. She sometimes understood simple, direct communication. She was sixty six inches tall and weighed ninety six pounds. She received more than fifty one percent of her nutritional intake through tube feeding. The resident's IDT care plan revealed an identified problem of nutritional risk and/or hydration related to the [DIAGNOSES REDACTED]. The resident received tube feedings, poor PO (oral) intake, on average consumes less than twenty five percent of meals, refuses PO fluids at times, start date 1/31/13. Goals included that the resident would have safe oral consumption over the next ninety days, goal date 5/1/12. Approaches included provide diet as ordered, resident also received tube feeding; provide cues/encouragement/assistance with the eating process. The care plan included an identified problem of resident appears somewhat demented, depressed, and disruptive throughout the day, start date 10/30/12. There were no approaches specific to behaviors during dining. The care plan included an identified problem of potential for injury, fall risk related to limited range of motion, cognitive impairment, poor safety awareness, weakness, unable to make needs known at times, unsteady gait, impaired vision, impaired mobility, resistive to care at times, able to wheel self once in wheelchair, start date 1/31/13. Approaches included the resident often gets scared and yells out if she finds herself in a group of people, staff to remove her from stimulus promptly and assure that she is all right, start date 1/31/13. Review of nurses' notes for 4/13 revealed no documentation of problematic behavior in the dining room for the resident. Observation: On 4/9/13 at approximately 5:30 p.m., the resident was observed in her wheelchair in the commons area. The resident was in close proximity to a small table in the commons room. A plate with a peanut butter and jelly sandwich cut in half and potato chips was observed on the table. The resident was alone in the commons area. The commons area was a room approximately sixteen feet by twenty feet, with two walls with large windows and with two entryways/exits. The commons area was out of sight of the dining room. The nurses' station was approximately twenty five feet from the resident with staff present, though no staff were observed to monitor the resident. The resident was asked if the sandwich and chips were her dinner, but she did not answer. The MDS Coordinator passed by the area, and was asked regarding the resident being alone with her meal in the commons area. The MDS Coordinator stated the resident was afraid of crowds, and would be brought by staff to the commons area to eat. She received tube feedings, so ate meals more for pleasure. Interview: On 4/10/13 at 9:00 a.m., the Director of Nursing (DON) was interviewed. When asked regarding the resident eating alone in the commons area, the DON stated that she did not have enough staff to always sit with residents who were moved to the commons area to eat due to behaviors. For this resident who received tube feeding, she pushed away from the table in the dining room. We have to depend on staff passing by to supervise a resident or residents eating in the commons area. She agreed that at times, no staff were present at the nurses' station to monitor for problems with residents eating in the commons area.

Based on observation, record review and interview, the facility failed to, based on the comprehensive assessment of a resident, ensure that a resident who entered the facility without pressure sores does not develop pressure sores; and a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically, for one (#8) of nine sample residents, the facility failed to ensure that a resident with a known pressure wound received timely pressure relieving devices to prevent the development of another pressure ulcer, failed to assure the wound was correctly assessed, and failed to ensure timely nutritional interventions were put into place as the resident continued to lose weight. Wound staging and measurements were not consistently documented. The facility failed to develop an effective plan to prevent the pressure ulcer from worsening, and failed to communicate effectively regarding wound status with an outside wound care resource. The facility policy, Assessment of the Integumentary System for Skilled Nursing Facilities, last reviewed 12/21/12, revealed, in pertinent part: The purpose: to ensure appropriate prevention and assessment of the skin according to American Medical Directors Association, Agency for Healthcare Research and Quality, and National Pressure Ulcer Advisory Panel guidelines and to meet the intent of F314. Consider any resident with history of pressure ulcer, or actual pressure ulcer to be high risk according to the Braden Scale. Factors to avoid for pressure ulcers Stages III and IV: 5) "Geri" chairs/recliners with less than 90 degree and greater than 30 degree sitting angles. Resident #8, according to the facility admission record was admitted to the facility, on 5/1/09, with [DIAGNOSES REDACTED]. The resident's most current Minimum Data Set (MDS), a significant change, dated 1/3/13, revealed the resident had a Brief Interview for Mental Status score of 00, indicating significant long- and short-term memory problems. She was assessed by staff regarding her mental state because she was unable to answer/recall any questions. She usually understood others, and was usually understood by others. She needed extensive assistance of one staff for bed mobility, transfer, dressing, and toilet use. She was totally dependent on staff for bathing. She was independent with eating with set up assistance. She used a wheelchair for mobility. She was sixty two inches tall and weighed ninety six pounds. She was at risk for pressure ulcers, but had no current pressure ulcer. She had an open lesion other than ulcers, rashes, or cuts. She had a pressure reducing device for the bed and chair, turning and repositioning, and an application of dressings and ointments. She had no nutritional or hydration interventions to manage skin problems. She received oxygen therapy, and was evaluated by Physical and Occupational Therapy. The facility, on 4/9/12 at approximately 4:45 p.m., provided a copy of an Acute/Temporary care plan dated 12/8/12 for the problem skin breakdown/pressure ulcers regarding a right scapular (upper back) wound open draining abscess. Interventions included: document skin assessment including wound measurements and description of each wound, dietitian consult, off-load pressure at all times. The resident's current care plan identified a problem of potential for skin breakdown related to impaired mobility, incontinence, decreased sensation, cognitive impairment, and fragile skin, start date 1/8/13. Interventions included inspect skin daily, daily pressure point checks by charge nurse, maintain adequate nutrition and hydration, provide measures to decrease pressure/irritation to skin, pressure reducing mattress and cushion to wheelchair, start date 1/8/13. Two care plans of actual skin breakdown were provided by the facility, revealing the resident had a pressure ulcer to left hip, potential for infection, start dates of 1/5/13 and 1/8/13. Approaches included pressure relief mattress to bed and cushion on wheelchair, encourage to let staff reposition while in chair and bed, she often refuses to lay down between meals or be put in her recliner, is being followed by wound care. The care plan of actual skin breakdown dated 1/5/13 had hand-written editions on 3/4/13 for Stage II to right shoulder, to be treated at wound care clinic, turn every 2 hours, prop with pillows. The nutritional care plan identified a problem of nutritional risk, related to [DIAGNOSES REDACTED]. The resident required nutritional supplementation, start date 1/8/13. There was no mention of wound healing issues. A goal of maintaining the weight of 104.6, plus or minus 3 pounds, had a goal date of 6/13/12. No nutrition/hydration interventions were updated after 3/15/12. A Physician Communication Sheet was observed in the record. The communication from nursing, dated 2/1/13, reported the following: Pressure ulcer on left hip has increased in size and area surrounding is red and nonblanching. Currently seen by wound care for wound to right midback. Can she have an order for [REDACTED]. Physician's notes were reviewed in the record, and revealed the following in pertinent part: 1/24/13 Patient here for follow up on chronic right shoulder blade decub (decubital) ulcer, continuing to see wound care, sees next week. 3/21/13 Patient here to follow up on wound care, seeing (other doctor) and he reports being happy with the way the wounds are healing. If we could get her nutritional status improved, will be even better. Physician computerized orders (CPO) revealed the following in pertinent part: Prostat 101 liquid 30 milliliters (ml) by mouth (PO) three times a day (TID) for wound healing, order date 12/28/12. Magic Cup one cup, PO twice daily for weight loss, order date 3/11/13. Med Pass 2.0 liquid 90 ml PO TID for weight loss, order date 3/11/13. Pressure relief measures continuous, order date 3/18/13. To right upper back, saline irrigation, hydrogel gauze packing, cover with ABD (dressing) and secure with paper tape, change daily, order date 3/18/13. To left hip wound, saline irrigation, hydrogel gauze, cover with ABD and secure with paper tape, change daily, order date 3/18/13. Turn every 2 hours, order date, 2/18/13. Skin assessment weekly, start 12/27/12. PUSH (Pressure Ulcer Scale for Healing) Tool daily, start 1/5/13. (PUSH Tool on Medication/Treatment Record written as weekly on Monday). Physician's telephone orders (TO) dated 4/1/13 revealed the following: Right shoulder [MEDICATION NAME] Border dressing, change every four days. Back wound, saline rinse, Hydrogel dressing, cover with [MEDICATION NAME] Border, change every other day. Left hip wound, saline irrigation, Hydrogel gauze, pack undermining, cover with ABD... Physician's TO dated 4/5/13 revealed the following: Pressure relief measures continuous, order date 3/18/13, discontinued on 4/5/12 as a repeat order. Discontinue turn every 2 hours due to placed on every 1 hour turn schedule. Interdisciplinary notes in the record included the following in pertinent part: 12/28/12 no time given. Daily Skilled Nursing Assessment. Pressure ulcer checked. (No staging was documented.) New wound care order right shoulder wound area. New order received for Prostat 101 30 ml TID for wound healing. 12/31/13 6:00 p.m. Daily Skilled Nursing Assessment. Resident positioned to relieve pressure to (right shoulder blade/mid upper back) wound. 1/1/13 9:00 a.m. Daily Skilled Nursing Assessment. Dressing to upper back changed. Wound draining yellowish green discharge. 7:00 p.m. Refused evening dose of antibiotics for shoulder wound. Pressure ulcer Stage III. 1/2/13 7:00 p.m. Daily Skilled Nursing Assessment. Geriatric chair maintained with pressure off of right back wound. 1/3/13 5:24 p.m. Daily Skilled Nursing Assessment. Resident has legs elevated in chair, pressure off right shoulder. 1/5/13 1:30 a.m. Daily Skilled Nursing Assessment. Upon rounds, resident is noted with a 3 centimeters (cm) by 4 cm pressure ulcer to her left hip. It is horseshoe shaped that is with dark necrotic tissue with surrounding circumference of redness. Center is open 0.5 cm circular with no drainage. 3:00 p.m. resident up in recliner. Resident off left hip and pillow behind right shoulder to keep pressure off wounds. Remains on antibiotics for wound infection. (Eschar present. No wound staging.) 1/6/13 no time given. Daily Skilled Nursing Assessment. Other [MEDICAL CONDITION] on right back was checked. 1/11/13 no time given. Daily Skilled Nursing Assessment. Weekly weight is 96.2, down 7.2 pounds. Intake 30 percent with Prostat 30 ml three times daily. Has a Stage II to left hip and wound to right shoulder. Stage II measures 2.0 cm by 2.5 cm had decreased in size. Will continue to weigh weekly and monitor skin. (No new intervention initiated for weight loss and second wound.) 1/14/13 no time given. Daily Skilled Nursing Assessment. Back wound draining yellowish drainage, left hip wound draining brownish yellow drainage. 1/20/13 6:00 p.m. Daily Skilled Nursing Assessment. Left hip wound with sanguineous drainage. It is now 90 percent open with granulation tissue to center but eschar to all surrounding edges. (Eschar present, no wound staging.) 1/22/13 no time given Daily Skilled Assessment. Stage II left hip. 1/24/13 1:40 p.m. Current weight 93.6 pounds, down 2.6 pounds from 1/9/13. Continues to have a Stage II pressure ulcer to left hip measures 3 centimeters (cm) by 2.3 cm and 1 cm by 1.2 cm and pressure area to right shoulder measures 3 cm by 3.5 cm. Will continue to monitor. Signed by MDS Coordinator, and RD. (Second hip wound. No depth given for measurements. No new nutritional interventions initiated with new wound to right shoulder and continue weight loss.) 1/25/13 4:00 a.m. Resident becomes combative with care, verbalizes that she will hit staff if we touch her, resident's left hip with drainage onto gown. Dressing changed. Signed by nursing. 1/30/13 12:17 p.m. Resident back from wound care, return in 2 weeks for right upper back. Keep pressure off wound. Signed by nursing. 1/31/13 5:00 a.m. Stage II pressure ulcer to left hip has large amount of drainage-serosanguineous; skin around ulcer is red and nonblanching. Dressing was soaked. Will consult wound care nurse for further instructions. Signed by nursing. 2/4/13 2:00 p.m. Received new faxed order for wound care to see resident's left hip. Signed by nursing. 2/16/13 4:30 a.m. Dressing to left hip has quarter-sized yellow/red drainage. Two wounds observed. One pencil tip with yellow slough. Larger with yellow slough at edges with black firm material, possible eschar. (Possible eschar, no wound staging) 2/18/13 4:00 p.m. Orders received from wound care. Low air mattress. Left hip pressure ulcer-saline irrigation, followed by Hydrogel packing, cover with ABD dressing with [MEDICATION NAME] tape, change daily. 2/19/13 Midnight. Resident's left hip dressing found at midnight rounds to be saturated with frank red/maroon blood. It has leaked out onto the depends. Both wounds are actively bleeding. 2/20/13 1:20 p.m. Late charting for 2/18/13. Small wound back of hip measures 2.1.cm by 1.7 cm. Left hip larger wound measures 5.6 cm by 4.0 cm. Tunnel at 12:00 0.9 cm, 03:00 0.5 cm, 06:00 1.8 cm. (No depth measurement documented. No wound staging.) 3/1/13 2:00 p.m. Resident on low air loss mattress. (First charting of low air loss mattress described as ordered from wound care on 2/18/13.) 3/4/13 3:15 p.m. Order change to puree diet due to decreased dietary tolerance. Signed by nursing. 3/4/13 4:15 p.m. Spoke with resident's Power of Attorney (POA) related to wound care orders (upon return to facility after wound care). POA stated would like increase in communication with staff and was assured this would happen. Signed by nursing. 3/5/13 4:00 a.m., Left hip with significant undermining to upper portion of wound creating a lip. Signed by nursing. (No wound staging or measurement of wound with undermining.) 3/8/13 1:30 p.m. Remains on low air loss mattress. Signed by nursing. 3/10/13 11:00 a.m. Resident is cooperative with care and continues to be turned every 2 hours. Signed by nursing. 3/15/13 2:40 p.m., Left hip pressure area measures 5.1 centimeters (cm) by 2.7 cm by 0.8 cm. Areas are decreasing in size, being followed by wound care center. Signed by MDS Coordinator and Registered Dietitian (RD). (Measurements documented in note were from 3/11/13 and were inconsistent with the previous skin assessments of the hip wound documented as Stage IV on 2/25/13 with depth of 2.6 cm. and on 3/4/13 as 5.8 cm by 4 cm by 2.8 cm.) 3/19/13 11:40 a.m., Wound care treatments provided to left hip, right shoulder, right upper back. Signed by nursing. (New pressure area right shoulder.) 3/20/13 4:15 a.m., Resident does well with repositioning throughout the shift. Signed by nursing. 3/21/13 3:40 p.m., Current weight is 88.4 pounds, down 1.2 pounds in past week. Meal intakes at 20 percent. Receiving Med Pass, Prostat and magic cup. Takes 50-75 percent. Continues to have a pressure ulcer to left hip and two pressure areas to right shoulder. Will continue to monitor weight and skin weekly. Signed by MDS Coordinator and RD. (Nutrition interventions ordered 3/11/13) 3/29/13 2:45 p.m., Current weight is down 85.6 pounds, down 3.8 pounds in one week. Will continue to monitor. Signed by MDS, RD, and Assistant Director of Nursing (ADON). (No new nutritional interventions since 3/11/13) Weekly Skin assessments were reviewed and revealed the following in pertinent part: 12/27/12 readmission assessment: two wounds on back, multiple bruises and a skin tear. The resident's readmission weight was 104 pounds. (No wound staging documented. No wound measurements.) 1/2/13 Pressure ulcer on right upper back, multiple bruises and a skin tear. Medium amount of drainage. (No wound staging. No wound measurements.) (No weekly skin assessment on 1/9/13.) 1/15/13 Pressure ulcers on right upper back and left hip. The wound was documented "not seen, dressings on". (No wound staging. No wound measurements.) 1/23/13 Pressure ulcers on right upper back and left hip. The wound was documented as "not seen, dressings on". (No wound staging. No wound measurements.) 1/30/13 Pressure ulcers on right upper back and left hip. The wound was documented as "not seen, dressings on". (No wound staging. No wound measurements.) 2/4/12 Open wound on right upper back. Stage II. Medium amount of drainage. (No wound measurements. No documentation of the resident's left hip.) 2/11/13 Right shoulder wound. Stage II. Medium amount of drainage. (No wound measurements. No documentation of the resident's left hip.) 2/18/13 Stage II. Small wound back of hip measures 2.1.cm by 1.7 cm. Left hip larger wound measures 5.6 cm by 4.0 cm. Tunnel at 12:00 0.9 cm, 03:00 0.5 cm, 06:00 1.8 cm. Wound on right upper back measures 2.9 cm by 1.9 cm by 0.8 cm. (No wound staging. No depth measurement on hip wounds. Initial second hip wound measurement.) 2/25/13 Stage IV. Left hip 6 cm by 4 cm by 2.6 cm. Small amount of drainage. (First Stage IV wound staging. No description of tunneling.) 3/4/13 Stage IV. Left hip 5.8 cm by 4 cm by 2.8 cm. Right upper back 2.8 cm by 2 cm by 0.5 cm. Stage II on right shoulder. Small amount of drainage. No description of tunneling. 3/11/13 No wound staging. Left hip 5.1cm by 2.7 cm, by 0.8 cm. Right upper back 0.8 cm by 0.6 cm by 0.2 cm. Small amount of drainage. (No description of tunneling. Depth inconsistent with measurements on 2/25/13 and 3/4/13.) 3/18/13 Stage III Left hip, right scapula, right shoulder. (No wound measurements. No description of tunneling.)) 3/25/13 No wound staging. Left hip, right scapula, right shoulder. Left hip wound 5.8 cm by 3.4 cm, (no depth). Right upper back 3.4 cm by 1.8 cm, (no depth). No description of tunneling. 4/1/13 No wound staging. Undermining yes, no description. Left hip measures 5.6 cm by 3.2 cm, (no depth), right upper back 3.2 cm by 1.6 cm, (no depth). 4/8/13 No wound staging. Undermining yes, no description. Left hip measures 5.6 cm by 3.2 cm, (no depth). Scheduled repositioning was circled "yes" on 1/15/13, 1/23/13, and 1/30/13, circled "no" on 2/25/13, and otherwise was not marked as a preventative measure. Support surfaces chair and bed nonspecific if pressure-reducing or pressure-relieving were circled as preventive measures. Tissue type charted as percentage of granulation or slough/eschar, consistent with the PUSH Tool were not charted on any weekly skin assessment. Observation: On 4/9/13 at 10:30 a.m., the resident's wound care was observed. A Registered Nurse (RN) with the assistance of the ADON, provided the wound care. The gauze was observed bunched in the center of the wound. No measurements were taken of the wound. The wound itself appeared consistent in size to the measurements provided on 4/8/13, and depth consistent with the 3/4/13 measurement. The tunneling appeared to be 2.5 to 3.0 cm over approximately 50 percent of the wound edges. The RN stated the measurements were done on the weekly assessment. She also stated that the wound clinic had expressed concern that the gauze was not being packed into the tunneling. She and the ADON stated that they always packed the tunneling, but it would compress to the center of the wound, as it was observed today. They had been working on figuring out how to keep it from compressing out of the tunneling. They didn't have very good communication with the wound clinic other than dressing change orders. Most of the facility's information came from the resident's family member who accompanied the resident to the clinic. The ADON stated she would accompany the resident to get information from the wound clinic. Interviews: On 4/9/13 at 2:30 p.m., the Director of Nursing (DON) was interviewed. She stated the resident's left hip wound was found early morning on 1/5/13. It was discovered on night shift. The pressure ulcer on the scapula area was thought by the Nurse Practitioner (NP) to have started in November as an abscess, then it tunneled. The resident went to the wound clinic. We were trying to keep the resident off of the right side and the left hip broke down. All of the beds are pressure reducing. If a resident has a pressure wound, we add a [MEDICATION NAME] to the mattress with alternating air flow. We had put an alternating air mattress overlay on the bed, and the wound clinic ordered a low air loss mattress. We rented one until we received the one the clinic ordered. The rental was ordered on [DATE], the invoice data was on 2/26/13, but she didn't know exactly when the bed was received. She further stated that she would have expected the resident to have an alternating air mattress overlay in place before the care plan indicated it on 1/8/13, because of the tunneling of the wound on the right scapula. She could not tell from the record when the air mattress was placed. The resident was already going to the wound clinic for the scapula wound, and they started seeing the resident for the left hip. She believed the wound was debrided. She did not see current measurements on the skin observation sheet. The facility did not get notes from the wound clinic to know how they measure or stage the wounds. The resident had later developed a second Stage II pressure area on her back below the scapula wound that healed. She also currently had a Stage II pressure area on her right shoulder. She stated the occurrence report included the original wound description. She did not reply when asked if the dark necrotic tissue described in the report made the wound not a Stage II, but Unstageable. She stated Physical Therapy recommended the "Geri" (geriatric) chair to help prevent falls, but the chair had no cushion. The resident was admitted to the hospital the end of December for [MEDICAL CONDITION]. The admitting physician charted the reason for admission was a decubitus ulcer (scapula)[MEDICAL CONDITION] and dementia. The resident was going to the wound care clinic for the scapular wound and started being seen for the left hip. She did not see current measurements on the skin observation sheet. She stated they did not get notes from the wound care clinic. The wound care clinic claimed they did not know about the left hip wound right away, that the facility did not communicate the wound, but we know we did because of wound care orders. She did not have any record of how the wound care clinic was measuring or staging the wound on the left hip. When she observed the skin assessments and Stage IV documentation, she stated she believed the left hip wound should be staged as a Stage III. At 4:30 p.m., the RD was interviewed. He stated he agreed that a nutritional intervention would be expected with the onset of a second wound and if wounds worsened. He stated he learned about wounds mostly by word of mouth. He did not attend the clinical rounds meetings during the week. He did not receive written notice if a resident developed a wound or if it worsened. He was not made aware the resident had a second pressure wound or that the wound had gotten worse or he would absolutely have put interventions in place between December 27th and March 11th. He had not been made aware that the resident's wound was documented worsening from a Stage II on 2/18/13 to a Stage IV on 2/25/13.

Based on record review and interviews, the facility failed to prevent the development of pressure ulcers for three (#10, #12 and #13) of 13 sample residents. Specifically, 1. For resident #10, the facility failed to monitor a reddened area on the coccyx and one week later a stage two pressure ulcer developed; 2. For resident #12, the facility failed to conduct weekly skin assessments to monitor the skin for two weeks and two stage two pressure ulcer developed; 3. For resident #13, the facility failed to assess the resident's risk for skin breakdown to ensure appropriate interventions were in place or consistently monitor the resident's skin. According to the facility plan of correction, the facility re-trained all nursing staff on conducting Braden scale assessments, weekly skin assessments, staging wounds and completing consistent wound documentation. All staff was trained on or before 5/9/13, the facility's alleged date of compliance. An onsite revisit occurred to the facility on [DATE] and 6/6/13. The findings include: 1. Resident #10, a [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the minimum data set (MDS) assessment dated [DATE], the resident scored a six on the brief interview for mental status (BIMS) which indicated severe cognitive impairment, was able to understand and be understood by others and had not rejected care. Additionally, the assessment indicated the resident required extensive assistance of one person for bed mobility, transfers, and personal hygiene. The resident did not have a pressure ulcer at the time of the assessment, however, the resident was at risk for developing pressure ulcers and had moisture associated skin damage. The care plan for the resident dated 4/9/13 noted the potential for skin breakdown. The approaches included: monitor skin weekly when bathing, monitor and encourage PO (by mouth) intake, offer snacks between meals, notify MD (medical doctor) as needed and assist with hygiene (with appropriate protective clothing) and ADLs (activities of Daily Living) as needed. The Braden Scale (a tool used for predicting pressure sore risk) dated 4/12/13 had a written score of 16, indicating the resident was at mild risk for skin breakdown. A. On 5/16/13, the weekly skin assessment revealed a reddened pinkish area to the coccyx. There were no other characteristics of the reddened area identified. Staff did not identify if the area was blanchable or not; indicating if a stage one ulcer was developing in this area. Further record review of the physician notes, physician telephone orders and nursing notes revealed there were no changes to the treatment plan, notification to the physician or revisions to the care plan. From 5/16/13 until 5/23/13, there was no further documented monitoring of the area. B. Seven days later, on 5/23/13, staff discovered two, stage two pressure ulcers had developed: The Treatment Administration Record (TAR) had written with the date 5/23/13, clean sites to right oschael with wound cleanser. Dx: (diagnoses) STG (stage) II x 2 sites right oscheal. Nursing notes dated 5/23/13: CNA (certified nursing aide) called nurse into resident's room. Noted two open areas to resident's right oscheal, MD (physician) notified. Site #1 measures 0.7 cm x 1.7 cm. Site #2 was lateral to site #1 and measured 0.6 cm x 0.6 cm. Review of the record indicated no previous wounds for the resident. An acute care plan dated 5/23/13 was written for a Stage II pressure ulcer to the resident's right oscheal. An overlay (air) mattress was implemented after the development of the ulcer. C. Interviews: On 6/6/13 at 10:54 a.m., a registered nurse (RN), who provided treatment for [REDACTED]. On 6/6/13 at 1:05 p.m., the resident stated her wheelchair was uncomfortable. Specifically, the resident stated her bottom hurt. The resident was observed to unsuccessfully attempt to change position in the wheelchair. On 6/6/13 at 1:46 p.m., the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed. After review of the resident's skin assessment, the ADON stated the 5/16/13 assessment noted reddened pinkish skin around coccyx. The ADON stated there were no additional documented interventions based on the 5/16/13 assessment. On 5/23/13, two pressure ulcers on the oscheal were documented. The DON and ADON stated there may have been additional interventions, however, there were none documented. 2. Resident #12, an [AGE] year old admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was on hospice services as of 4/18/13. According to the MDS dated [DATE], the resident scored a 15 on the BIMS which indicated the resident was cognitively intact. The assessment also indicated the resident was usually understood and able to understand others, had not rejected care, required extensive assistance of one person for bed mobility, transfers and personal hygiene. The resident was noted to be at risk for the development of pressure ulcer, did not have any pressure ulcers and pressure reduction devices were placed in the bed and on the wheelchair. The care plan for the resident dated 4/18/13 indicated the potential for skin breakdown (the word unavoidable was penned into this care plan) related to hospice care, end of life care, occasional bladder incontinence, impaired mobility, cognitive impairment, assistance with ADLs/toileting. The approaches included: keep skin clean and dry, Inspect skin daily with ADLs, weekly skin assessment and document findings, maintain adequate nutrition and hydration, Braden Scale quarterly and keep bed linen clean and dry. The most recent Braden Scale dated 4/13/13 noted a score of 16 which indicated mild risk for pressure sore development. A. TAR dated 5/27/13 Dx: opening to coccyx x 2 Nurse's notes dated 5/27/13: new openings found at base of coccyx, #1 measured 0.7 cm x 0.5 cm, #2 measured 0.2 cm x 0.2 cm. The notes did not indicate a pressure ulcer prior to 5/27/13. An acute care plan dated 5/27/13 was written for Stage II to coccyx. B. Weekly skin observation documents indicated a weekly skin assessment was performed on 5/7/13 and the next documented assessment on the same sheet of paper was dated 5/28/13 (one day after the identification of two stage II pressure ulcers). There were no skin assessments by the nurse on 5/14/13 or 5/21/13. C. Interviews: On 6/6/13 at 1:46 p.m., the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed. After review of the resident's skin assessment, the ADON stated the resident had a skin assessment on 5/7/13 and the next documented skin assessment was dated 5/28/13, one day after the identification of the stage II pressure ulcers. The DON and ADON stated the facility expectation was for the weekly assessment to be performed weekly, and the missing two weeks was not acceptable. Additional Information: The facility provided additional documentation to indicate an outside provider had performed skin assessments during the missed opportunities by the facility, however, one of these was performed by an RN, three others were performed by a home health aide and the facility did not provide additional documentation to indicate the assessments had been performed weekly by facility staff as outlined in the plan of care. 3. Resident #13, a [AGE] year old who was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. According to the MDS dated [DATE], the resident scored a five on the BIMS which indicated severe cognitive impairment, was able to sometimes understand or be understood by others, had not rejected care, required extensive assistance of two persons for bed mobility, transfers and personal hygiene. The resident was identified as being at risk for development for pressure ulcers and pressure reduction devices were applied to the bed and wheelchair as well as a turning schedule for the resident. The care plan for the resident dated 3/19/13 noted the potential for skin breakdown, approaches included: keep skin dry and clean, peri-care after each incontinent episode, scheduled toileting, inspect skin daily with ADLs and report findings to nurse, maintain adequate nutrition, Braden Scale quarterly, keep bed line clean and dry. A. The most recent Braden Scale was dated 12/29/12 (see care plan above; see interview below) and noted a score of 16 which indicated mild risk for developing a pressure sore. B. Review of the weekly skin assessment, dated 5/13/13, revealed no skin issues. There was no skin assessment completed the following week. C. Two weeks, after the last skin assessment on 5/13/13, the resident developed a pressure ulcer: The TAR dated 5/27/13 noted Dx: open area to right oscheal. The Nurse's notes dated 5/27/13: new opening found on resident's right oscheal measures 0.7 cm x 1.6 cm, resident unaware of how she got the opening. No documented wounds prior to this note. An acute care plan dated 5/27/13 was written for a Stage II pressure ulcer to right oscheal. D. Interviews: On 6/6/13 at 1:46 p.m., the director of nursing (DON) and the assistant director of nursing (ADON) were interviewed. After review of the resident's skin assessment, the ADON stated the resident had a skin assessment on 5/13/13 which noted no concerns. The ADON stated there should have been a weekly skin assessment completed on 5/19/13 and stated there was no documentation to indicate the assessment had been completed on that date. The DON stated the expectation was for weekly skin assessment to be performed every week. The ADON confirmed there was a two week period between the last documented assessment, a missing assessment and the identification of a pressure ulcer. The ADON stated the last documented Braden Scale was dated 12/29/12 and stated the expectation was for this assessment to be completed quarterly and this had not been done.

Based on interviews and record reviews, the facility failed to respect the emergent care choices of one (#1) of five sample residents. Specifically, Resident #1 had specified, at the time of her admission to the facility, that she desired full emergency care to be provided to her and these services were not provided to her. Findings include: Resident #1 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review: The transfer assessment dated [DATE] indicated the resident was pleasant and followed commands, and was cooperative. She was alert and oriented. She had a Stage III coccyx wound. She was receiving feedings via a PEG tube. She could walk with a walker with assistance. The resident's face sheet listed her son's name and number, with notation, "Power of attorney RESPONSIBLE FOR FINANCES". A Colorado Medical Orders for Scope of Treatment (MOST) form was signed on [DATE] by the resident and recorded as "self" with an accompanying health care professional's signature witnessing the form. The form was completed to indicate the resident desired cardiopulmonary resuscitation (CPR), full treatment including intubation, advanced airway interventions, mechanical ventilation and cardio-version as indicated, the use of antibiotic when comfort was the goal and artificial nutrition/hydration by tube for one month with the goal of full recovery. A progress note on [DATE] at 5:45 a.m., stated the resident was expressing anxiety and said she had a long history of anxiety. The nurse recorded that she sat with the resident to attempt to ease her anxiousness and the oncoming shift was notified of the resident's condition. A progress note on [DATE] at 5:30 p.m., stated the resident had been assessed at 3:30 p.m., and was experiencing a nosebleed. She denied pain, but complained of nervousness. Her vital signs were temperature 97.8, respirations 20, and pulse was 96. A second progress note at 5:30 p.m. read, "Called son/POA stating is it OK to send to ER related to nosebleed not stopping and blood in stomach causing discomfort. Completed paperwork and went to check on resident at 5:10 p.m. Resident not breathing, no pulses, no blood pressure. No heart rate to auscultation. Pale with skin and upper extremities cool. Chest compressions started for one minute with no response. Alerted other staff and called son/POA. Stated to not send to ER. Physician called and pronounced dead at 5:30 p.m. Family stated not coming in to facility. Mortuary contacted." Interviews: A floor nurse was interviewed on [DATE] at 2 p.m. via telephone. The nurse was asked how she learned about the resident's death. She said that she came on to work the night shift and was told in report that the resident had passed away. She said the floor nurse said she found the resident, did CPR for about a minute and then called the son who said not to send her to the emergency room . She said she asked the floor nurse if she knew the resident was a full COR and the nurse replied that she did, but didn't call emergency services because she thought she was "basically gone". The social worker was interviewed on [DATE] at 2:30 p.m., and said that she didn't talk to the resident because the resident was admitted on a Friday afternoon and died the following Sunday. She said the advanced directive form (MOST) form was filled out by the nurse on duty the evening the resident was admitted . She said she did not have any contact with the resident's family after the resident's death. On [DATE] at 4:45 p.m., the unit nurse who signed the MOST form with the resident was interviewed via telephone. She said she was on duty the night the resident was admitted . She said the resident had been very ill, but she was alert and oriented, with no indications of any type of mental impairment. She said she filled out the MOST form with the resident and that the resident was her own power of attorney. She said she asked if the resident wanted to be Do Not Resuscitate (DNR) and the resident replied, "When I went into the hospital, I said I wanted to be DNR, but while I was there, I thought about it a lot, and I changed my mind, I want everything done". The nurse said she then read through the form completely for the resident, and the resident signed the form without any assistance, indicating she wanted all emergency medical treatment done. On [DATE] at 3:15 p.m., the Medical Director was interviewed via telephone. He said that he visited the facility approximately once a month and participated in the facility's Quality Assurance program. He said he had not been made aware of any of the circumstances of this particular resident's death and did not want to comment on the case specifically because he had not been able to review the resident's medical record. He said that generally speaking if a resident had signed the MOST form and they were their own POA, indicating they wanted all emergency medical services provided to them in the event of an emergency, CPR should be provided until emergency medical services arrived or the CPR administrator was too fatigued to continue. He said in a person of advanced age with full COR status, the physician should be called while CPR was being conducted after emergency services were summoned, and at that time the physician could make the decision to stop CPR. On [DATE] at 1:35 p.m., the unit nurse who cared for the resident the night of her death said the resident had experienced a persistent nose bleed prior in the evening and was feeling nauseated. She said at dinner the resident said she was not feeling well, but was lucid and alert. It was the nurses' belief that the resident's nosebleed was making her nauseated. She called the resident's son to see if the resident could be taken to the emergency room for care. When she returned to the room approximately fifteen minutes later, the resident appeared unresponsive. The nurse said she then started CPR. She said she attempted to call for help with her radio, but got no response, so she looked down the hall, summoned an aide and told him to get the other floor nurse. She said she returned to the room and continued CPR. Asked how long she performed CPR, she said, "It was at least 15 minutes before I stopped." She said in the meantime, the other nurse came in to assist her. She said she called for the crash cart and a staff person brought the crash cart to the room, but she was not certain who had done that. She said she called the physician who told her to stop CPR. She said she then called the resident's son to tell him what had occurred. Asked if she called the physician or the son first, she said, "I probably called the physician first." She called the son, explained what happened and "He was OK with it." She was asked if she knew the resident was full COR status and she said, "Yes, I knew that." She said a full COR meant that CPR should be initiated and emergency medical services should be called. Asked why she stopped CPR in this instance, she said the doctor told her to stop. She said she did not call emergency services. On [DATE] at 4 p.m., the second floor nurse on duty the night of the resident's death was interviewed. She said she was in the dining room when an aide came running in and said "(Nurse's name) needs you!" She said she could tell by his demeanor that this was an emergency situation. She said it took approximately a minute for her and the aide to get to the resident's room. She said she did not see the nurse administering CPR when she entered the room and did not hear the nurse call for the crash cart. She said to her knowledge the crash cart was not taken to the resident's room. She said she told, "yelled at", the other nurse three times that she should call 911, but the nurse did not do that. She said the nurse left the room and came back to say she had called the resident's son and she was not going to call emergency services because he said not to send her to the emergency room . She said she did not hear the nurse call the physician. The nurse said no emergency staff came to the facility to her knowledge. She said she did not see any family members at the facility that night. She said she was aware the resident was designated as a full COR. When asked what procedures were to be completed if a resident was full COR, she said, "We are to do CPR, summon emergency services, and continue CPR until emergency services arrive to take over." On [DATE] at 4:20 p.m., the nurses' aide (CNA) was interviewed. He said he was working on the floor the evening the resident died . He said he heard his radio "crackle" but the message was unintelligible, so he went down the hall trying to determine who was calling. He said he saw the nurse stick her head out of the resident's room door and she told him to get the other nurse as soon as possible. He said he ran to the dining room and told the other nurse she was needed quickly and together they ran to the resident's room. He said between the time the nurse told him to get help and he and the other nurse arrived at the resident's room was one to two minutes at the most. He said he did not see the nurse performing CPR on the resident when he entered, that when he entered CPR had already ceased. He said he did not see the crash cart in the room and did not see anyone bring a crash cart to the room. He said the resident was in bed, the enteral tube feeding was turned off, the head of the head was elevated. He said after the nurse said the son said to stop, he and another aide prepared the body for transport. The Director of Nurses was interviewed on [DATE] at 5:10 p.m. She said she expected full COR procedures to be followed when advance directives had been determined. She also stated the full COR designations were found on the front of the residents' charts. She said if a MOST form is not on file for the resident, the resident is to be considered on full COR status. She was asked if she expected nurses to continue CPR on a resident until emergency medical services arrived in the event of a medical emergency and she said, "yes". She said she was aware of the situation that was being investigated and had talked to the nurse about what had happened. She said the nurse said she performed CPR for "about a minute" and then called the resident's son who told her to stop CPR. She asked what the nurse's version of the events were when interviewed, and when these were relayed she said, "Her story has changed. She told me she did CPR for a minute and then called the son." She said no further education regarding emergency procedures had been provided to staff after this event.