Every finding on record at Westlake Health and Rehabilitation Center

Based on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on one of two units.Specifically, the facility failed to:-Ensure the facility was free from excessive noise; and,-Ensure residents were provided with hand towels.Findings include:I. Failure to ensure the facility was free from excessive noiseA. Facility policy and procedure The Safe and Homelike Environment policy and procedure, revised 10/1/24, was provided by the regional clinical resource on 8/20/26 at 4:56 p.m. It read in pertinent part, The facility will create and maintain, to the extent possible, a homelike environment that de-emphasizes the institutional character of the setting. The facility will maintain comfortable sound levels in the facility. Maintain minimal use of alarms, using alternative interventions, unless otherwise indicated by the care plan.B. ObservationsA door chime for the south unit smoking patio played a song for approximately twelve seconds each time the door was opened. The door chime was audible from each end of the south unit and from the main dining room.On 8/19/26 between 1:21 p.m. and 5:43 p.m. the chime played 68 times.On 8/20/26 between 8:21 a.m. and 11:10 a.m. the chime played 47 times.C. Resident group interviewThree residents who frequently attended monthly resident council meetings (#29, #10 and #93) were interviewed on 8/19/26 at 9:39 a.m. Resident #93 said the door alarm went off all day and night. Resident #93 said he was so sick of the song the alarm played and said he wanted to rip the alarm off the wall. Resident #29 said the door alarm bothered him. Resident #93 and Resident #10 said they wished the facility would at least change the song the alarm played every once in a while. All residents in attendance said the alarm going off made them feel like they were crazy.D. Resident and resident representative interviewsResident #70 was interviewed on 8/19/26 at 2:32 p.m. Resident #70 said she did not hear the door chime often in her room, but heard the chime when she was in the hallways or closer to the smoking door. Resident #70 said if she was closer to the door and heard the alarm go off all day she would go nuts.Resident #85 was interviewed on 8/20/26 at 1:14 p.m. Resident #85 said she recently moved rooms and used to live on the south unit. Resident #85 said hearing the smoking door chime definitely bothered her.Resident #54's representative was interviewed on 8/19/26 at 2:11 p.m. The resident's representative said she was at the facility for a few hours each day, and said the smoking door alarm went off constantly while she visited. The resident's representative said hearing the door alarm go off bothered herself and Resident #54.E. Staff interviewsLicensed practical nurse (LPN) #4 was interviewed on 8/20/26 at 10:56 a.m. LPN #4 said the chime to the smoking door went off all day long. LPN #4 said the residents seemed to understand it was a safety feature to let staff know when other residents went out of the smoking door so they did not seem to mind.The nursing home administrator (NHA) was interviewed on 8/20/26 at 4:55 p.m. The NHA said she had not heard any concerns from residents about the smoking door alarm. The NHA said when she first started working at the facility she thought the alarm was too loud so she had turned it down quite a bit. The NHA said she would bring the door alarm up in resident council to see what the residents thought of it, or that she could just turn the alarm off.II. Failure to ensure residents were provided with hand towelsA. Facility policy and procedure The Safe and Homelike Environment policy and procedure, revised 10/1/24, was provided by the regional clinical resource on 8/20/26 at 4:56 p.m. It read in pertinent part, The facility will provide and maintain bed and bath linens that are clean and in good condition.B. Resident, representative interviews and observationsResident #33 was interviewed on 8/17/26 at 11:31 a.m. Resident #33 said the facility staff did not bring in hand towels for her to dry her hands. Resident #33 said herself, as well as a lot of people at the facility, would probably use hand towels if they had them. -No hand towels were observed by Resident #33's sink or around her room.Resident #10 was interviewed on 8/17/26 at 2:59 p.m. Resident #10 said his room had hooks for hand towels but said the facility staff never provided him with any hand towels. Resident #10 said he had not had any hand towels in his room throughout the duration of his time in the facility. Resident #10 said it would be nice to have a hand towel to use to wash his face or dry his hands instead of having to use a whole body towel.-No hand towels were observed by Resident #10's sink or around his room.Resident #70 was interviewed on 8/17/26 at 3:12 p.m. Resident #70 said the facility staff used to bring in hand towels for her to use, but it had been a long time since they brought any in for her or her roommate. Resident #70 said she had to use her hand each morning to wash her face, and said it would be nice to use a washcloth to wash it instead. Resident #70 said her roommate also liked to wash her face in the mornings and said she thought she would want a washcloth as well.-No hand towels were observed by Resident #70's sink or around her room.Resident #54's representative was interviewed on 8/19/26 at 2:11 p.m. The resident's representative said Resident #54 never had hand towels available in his room. The resident's representative said she really wished Resident #54 had a hand towel available so she could use it when she visited and so Resident #54 could use it. -No hand towels were observed by Resident #54's sink or around his room.On 8/18/26 at 8:47 a.m. a hand towel was hanging from the hooks near the sink in Resident #12 and Resident #5's rooms. A body towel was hanging from the hand towel hook by the sink in Resident #28's room. All other rooms in the south hall were observed with empty hand towel hooks. The hand towel hooks in Resident #70, Resident #54, Resident #33 and Resident #10's rooms were observed to be empty during multiple observations from 8/17/26 through 8/20/26.C. Resident and resident representative interviewsD. Resident group interviewThree residents who frequently attended monthly resident council meetings (#29, #10 and #93) were interviewed on 8/19/26 at 9:39 a.m Resident #29 and Resident #10 said they did not receive any hand towels in their rooms. Resident #93 said he had to get his own hand towels. All of the residents in attendance said they would use hand towels if the facility staff provided them, and said they would prefer cloth hand towels to using paper towels.E. Staff interviewsRestorative nurse assistant #1 was interviewed on 8/20/26 at 1:23 p.m. Restorative nurse aide #1 said hand towels were available and stocked on the linen carts. Restorative nurse aide #1 said residents just had to ask the staff for a wash cloth and they would provide the resident with one.Certified nurse aide (CNA) #4 was interviewed on 8/20/26 at 1:11 p.m. CNA #4 said she was not sure who restocked hand towels in residents' rooms. CNA #4 said she thought the housekeeping staff may have restocked the hand towels since they were the staff responsible for restocking other goods like toilet paper in residents' rooms.LPN #4 was interviewed on 8/20/26 at 10:56 a.m. LPN #4 said the facility CNAs restocked residents' hand towels randomly and replaced them as needed.The housekeeping supervisor was interviewed on 8/20/26 at 3:48 p.m. The housekeeping supervisor said she restocked linens in residents' rooms. The housekeeping supervisor said she went through each resident's room to ensure they had hand towels stocked once per week, and ensured residents had hand towels available each day.The housekeeping supervisor said residents should have a hand towel available in their room at all times, and all staff were supposed to ensure they had hand towels available. The housekeeping supervisor said the CNAs and housekeeping staff were both supposed to ensure the residents had hand towels available. The housekeeping supervisor said the facility had not had any issues with hand towels running low or running out. The housekeeping supervisor said the hand towels provided to the residents may not be hanging up by their sinks but were sometimes placed on the resident's bedside table or their dressers.-However, observations conducted throughout the survey process did not reveal any hand towels accessible in several resident rooms (see observations above).

Based on observations, record review and interviews, the facility failed to ensure one (#4) of four residents were free from significant medication errors out of five sample residents. Specifically, the facility failed to ensure Resident #4 did not receive another resident's medications. Findings include: I. Professional reference According to Clinical Nursing Skills & Techniques by [NAME], [NAME] & [NAME], 8th Edition (2021), page 480-489, Safe medication administration: To prevent medication errors follow the six rights of medication administration consistently every time you administer medications. Many medication errors are linked in some way to an inconsistency in adhering to the six rights: -The right medication; -The right dose; --The right patient; -The right route; -The right time; and, -The right documentation. Read the label on the medication container and compare it with the MAR (medication administration record) at least three times before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication to the patient. Medication errors often harm patients because of inappropriate medication use. Errors include inaccurate prescribing; administering the wrong medication, by the wrong route, and in the wrong time interval; and administering extra doses or failing to administer a medication. II. Resident #4 A. Resident Status Resident #4, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included type 2 diabetes mellitus with hyperglycemia, unspecified atrial fibrillation, acute diastolic (congestive) heart failure, chronic kidney disease, stage 3, essential (primary) hypertension, gout, dysthymic disorder, insomnia and muscle weakness. According to the 3/13/25 minimum data set (MDS) assessment, the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 12 out of 15. She was dependent on a wheelchair for mobility. She needed supervision with activities of daily living (ADLs). The MDS assessment indicated the resident was receiving hypoglycemic (lowering blood sugar) medication and an anti-hypertensive (lowering high blood pressure) medication. B. Resident interview Resident #4 was interviewed on 6/25/25 at 3:00 p.m. Resident #4 said she remembered receiving another resident's medications. She said the facility told her that she was given the wrong medications accidentally. She said she felt dizzy and she had a stomachache all night. She said she was not able to eat for 24 hours. C. Record review The 5/15/25 progress note, documented at 12:59 p.m., revealed that licensed practical nurse (LPN) #1, who was an agency staff nurse, administered the incorrect medications to Resident #4. The note indicated LPN #1 notified the physician, the director of nursing (DON) and the resident's representative. The note revealed that Resident #4's vital signs were taken and found to be within normal range for the resident. The progress note revealed that Resident #4 was free of discomfort and adverse reaction. Review of the facility investigation for the medication error revealed Resident #4 was administered Lisinopril 40 milligrams (mg), duloxetine 60 mg and bupropion 300 mg ER (extended release). -Review of Resident #4`s May 2025 CPO revealed she did not have physician's orders for Lisinopril (treats high blood pressure), duloxetine (antidepressant medication) or bupropion (antidepressant medication). III. Staff interviews The DON was interviewed on 6/25/25 at 12:17 p.m. The DON said Resident #4 was administered another resident's medications on 5/15/25. The DON said the medications the resident accidentally received included Lisinopril 40 milligrams (mg), Duloxetine 60 mg and Wellbutrin 300 mg ER (extended release). She said the LPN who administered the wrong medications to the resident was an agency nurse. The DON said her first day of work in the facility was 5/14/25. She said the medication error with Resident #4 occurred the next day, on 5/15/25, and she was not yet familiar with the staff or the residents. She said the corporate clinical resource nurse provided medication administration education to all nurses in the facility after the medication error. She said the agency LPN (LPN #1) did not return to the facility.

Based on observation, record review and interviews, the facility failed to ensure one (#12) out of four sample residents were free from significant medication errors. Resident #12, who was admitted to the facility on [DATE], had a mechanical heart valve and was at a high risk for deep vein thrombosis (DVT). The resident had a physician's order to receive warfarin (a bloodthinning medication) to assist with preventing blood clots. Additionally, the resident had a physician's order to periodically monitor the resident's PT/INR (prothrombin time test/international normalized ratio - a blood test that measures how long it takes the blood to clot). The resident's physician adjusted the resident's warfarin dose based upon the results of the PT/INR blood test. According to the pharmacist ([NAME]), Resident #12's therapeutic level of warfarin (PT/INR goal range) was 2.5 seconds to 3.5 seconds (see [NAME] interview below). On 2/17/25 a physician's order was obtained to hold Resident #12's warfarin medication on 2/18/25 and 2/19/25 due to a PT/INR level of 4.84 seconds, which meant the resident's blood clotting time was too high. The facility was to recheck the PT/INR and give a one-time dose of warfarin 4 milligrams (mg) on 2/20/25. The resident's PT/INR was rechecked on 2/20/25 and was 3.12 seconds. The facility's nurse received a verbal physician's order to restart Resident #12's warfarin at 3.5 mg and recheck the PT/INR the following Wednesday (2/26/25). However, the facility failed to ensure the 2/21/25 physician's order for warfarin was transcribed into the electronic medication record (EMR) and onto Resident #12's February 2025 medication administration record (MAR), which resulted in a failure to provide anticoagulant medication for seven days and led to a significant reduction in Resident #12's PT/INR level to 0.97 seconds (indicating the resident's blood clotting time was too low, potentially increasing the risk for the resident to develop blood clots). The facility's failure to administer Resident #12's anticoagulant therapy for seven days led to a non-therapeutic PT/INR level and placed Resident #12 at greater risk for a blood clot. Resident #12 developed a blood clot in his right leg and later required an above the knee (AKA) amputation. The facility's failure to ensure staff accurately transcribed Resident #12's physician's order for warfarin resulted in a situation of serious harm. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/2/25 to 4/7/25, resulting in the deficiency being cited as past noncompliance with a correction date of 3/21/25. I. Situation of serious harm The facility failed to ensure Resident #12's 2/21/25 physician's order for warfarin was transcribed into the resident's EMR and onto the resident's February 2025 MAR, which resulted in a failure to provide anticoagulant medication for seven days and led to a significant reduction in Resident #12's PT/INR level. The facility's failure to administer Resident #12's anticoagulant therapy for seven days led to a non-therapeutic PT/INR level and placed Resident #12 at greater risk for a blood clot. Resident #12 developed a blood clot in his right leg and later required an above the knee (AKA) amputation. The failure to ensure staff accurately transcribed Resident #12's physician's order for warfarin resulted in a situation of serious harm. II. Facility's plan of correction The corrective action plan implemented by the facility in response to Resident #12's serious medication error on 2/21/25 was provided by nursing home administrator (NHA) #1 on 4/4/25 at 10:33 a.m. The stated purpose of the plan was to address the significant medication error and prevent any additional residents from suffering an adverse outcome. The plan revealed the following: Identification of others - the facility took the following actions to prevent an adverse outcome from reoccurring. All applicable facility policies and procedures were reviewed/revised by the director of nursing (DON) or designee (completion date 3/21/25). Systemic changes - the DON or designee re-educated licensed nurses on facility policies regarding medication transcription as well as transcribing physician's orders and notifying the physician. All nurses were educated prior to working their next shift. The DON completed corrective action and one-to-one education with a licensed nurse who was identified as being deficient in their practice resulting in this citation. A complete medication review will be completed on all residents who are prescribed warfarin. Monitoring - the DON or designee will complete weekly chart audits on all residents receiving warfarin medication to ensure the orders were transcribed properly, the medication was given as ordered/parameters followed, the physician was notified when there was a medication transcription error and the physician contact is properly documented. The audits will continue until compliance can be maintained three days (audits) per week for three consecutive months. The administrator implemented a QAPI/PIP (quality assurance and performance improvement/performance improvement project) as a means to gather and process information from the audits. Findings will be reported at the monthly quality assurance meeting for a minimum of three months. Date of compliance: 3/21/25. III. Facility policy and procedure The Anticoagulant Therapy policy, revised October 2024, was provided by NHA #1 on 4/7/25 at 4:42 p.m. It read in pertinent part, The anticoagulant medication administration record (MAR) is completed for residents receiving oral warfarin (brand name replaced) therapy. Complete the MAR, including the usual resident identifying information and the order date, warfarin dosage and dates for INR laboratory (lab) testing due in the boxes as indicated. As medications ordered are changed or laboratory results become available, the MAR is updated to include the new information. For any anticoagulant use, the facility will monitor for signs and symptoms of bleeding as needed. The warfarin log is completed for each resident receiving warfarin therapy. The log is completed with the usual resident identifying information, as well as the resident's initial INR range or goal according to the physician. Subsequently, resident INR laboratory results, medication dosage orders and dosage changes are recorded by the nurse in charge. Log follow up is assigned to one nurse for periodic auditing to ensure appropriate completion of the log. Prior to administering warfarin, please reference the warfarin tracking form. IV. Facility investigation of transcription omission and education provided in response to Resident #12's serious medication error on 2/21/25 NHA #1 provided a timeline of the investigation, the facility's findings and the education plan on 4/4/25 at 10:33 a.m. The information provided revealed the following: The investigation revealed a transcription error was noted on 2/21/25 and was the reason Resident #12 missed his warfarin from 2/21/25 to 2/27/25. The nurse received an order on 2/21/25 for 3.5 mg warfarin daily and to recheck INR on 2/26/25. She completed the warfarin log with the information about the new warfarin dosage, but did not transcribe the order into Resident #12's EMR. On 2/27/25 another nurse noted there was no current order for warfarin for Resident #12. The nurse who discovered the error obtained a physician's order for an INR. When the results came back, a different nurse (the night shift nurse) contacted the on-call provider and obtained a one-time physician's order for warfarin 4 mg with orders to follow up with the resident's usual physician for additional doses. No further misses for warfarin were found. A performance improvement plan was initiated by the facility on 3/13/25 and staff education was provided. The staff education document, which contained 16 licensed nursing staff signatures, revealed the following in pertinent part, A detailed progress note should be placed in the residents' charts summarizing the lab results, physician notified, and any new orders given or orders to continue the same dose and next INR draw. Nurses are responsible for updating the order in the EMR and verifying its accuracy. In the warfarin (log) book, the date, current warfarin orders and INR results and next INR draw should be recorded, as well as what the medication dosage was changed to or if the same dose is to be continued. Please note any misstep in this process could result in life threatening harm to the resident. V. Resident #12 A. Resident status Resident #12 Resident #12, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included right leg above the knee amputation, respiratory failure, aortic (heart) valve disorder, cerebral infarction (stroke), thoracic aneurysm (weakened area in body's main artery in the chest) and epilepsy. The 3/12/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of 11 out of 15. He required set up assistance with eating, and was dependent on staff for toileting, showering, dressing, repositioning and transferring. B. Resident observation and resident representative interview Resident #12's representative was interviewed on 4/7/25 at 12:55 p.m. The representative said as Resident #12 was being transferred to the hospital on 3/12/25, she overheard a facility nurse tell another nurse that the resident was accidentally taken off Coumadin (warfarin) for a period of time. The representative said she wanted to learn more about this when Resident #12 was readmitted to the facility, however, the facility refused to discuss what had happened during the care conference meeting after the resident's readmission. The representative said the facility representative at the care conference told her they would schedule another time to discuss the resident's missed warfarin doses, yet this had not happened. The representative said Resident #12's INR level was supposed to be maintained between 2.5 seconds to 3.5 seconds and the facility had not done a good job maintaining the resident's INR at the desired level. The representative said the hospital physician told her it was difficult to determine if the missed warfarin doses could have contributed to Resident #12's leg being required to be amputated, as his leg had circulatory issues for years. During the resident representative's interview, Resident #12 was observed to repeatedly say they cut off my leg several times. C. Record review Resident #12's anticoagulant therapy care plan, revised 3/28/25, documented the resident received an anticoagulant due to atrial fibrillation (an irregular heart beat that causes poor blood flow). The interventions included obtaining labs as ordered, monitoring and reporting signs/symptoms of thromboembolism (when a blood clot breaks off and travels through the bloodstream), monitoring, documenting and reporting to the physician as needed signs of anticoagulant therapy complications, resident teaching, reviewing medication list for interactions and ultrasounds as ordered per physician. An additional anticoagulant therapy care plan was initiated on 3/11/25, documented Resident #12 was at risk for deep vein thrombosis (DVT, a blood clot in a deep vein) related to the resident's history of DVTs, a mechanical heart valve, immobility and chronic anticoagulant therapy. The interventions included administering medications as ordered, monitoring and documenting side effects and effectiveness, inspecting legs and feet for skin color/temperature, monitoring laboratory values to monitor and document effects of anticoagulant therapy, reporting lab values outside desired range, monitoring, reporting, and documenting to the physician as needed any signs and symptoms of complications and repositioning and ambulating the resident as frequently as possible, at a minimum of every two hours. The anticoagulant therapy flowsheet for Resident #12 was provided by NHA #1 on 4/4/25 at 10:33 a.m. It documented the diagnoses requiring Resident #12's anticoagulant therapy included atrial fibrillation, mechanical heart valve and recurrent DVT. The documented goal for the INR level was 2.5 to 3.5. The flowsheet had labeled columns to enter the date, the INR level, the current warfarin dose and any new physician's orders. Resident #12's flowsheet documented the following: On 2/18/25, the INR result was 4.84, the current dose documented was 4 mg warfarin, and there was additional written documentation to hold the warfarin for two days and recheck 2/20/25, per physician assistant (PA). On 2/20/25, the INR result was 3.12, the current dose was documented that warfarin was on hold. -However, the February 2025 MAR revealed warfarin 4 mg was administered to Resident #12 on 2/20/25. On 2/21/25, the INR result was again documented as 3.12, the current dose documented warfarin 3.5 mg daily and there was additional documentation to recheck the resident's INR on 2/26/25. -However, the EMR revealed no daily physician's order for warfarin 3.5 mg to begin on 2/21/25 and review of Resident #12's February 2025 MAR revealed there were no documented doses of warfarin administered to the resident between 2/21/25 and 2/27/25 (a period of seven days). On 2/27/25, the INR result was 0.97, and there was no documentation for a current warfarin dose, however, there was additional documentation for a stat (immediate) INR. -However, review of the lab results revealed Resident #12's INR was 0.97 on 2/26/25 and the INR was actually 0.92 on 2/27/25. The INR flow sheet did not have an INR entry documented on 2/26/25. The INR flowsheet further revealed there was no documentation for a current dose of warfarin from 2/27/25 until 3/4/25. -However, review of the EMR revealed a physician's orders for warfarin beginning on 2/28/25. Review of Resident #12's February 2025 and March 2025 MAR revealed the resident received all doses of warfarin from 2/28/25 to 3/4/25. A physician progress note, dated 3/7/25, documented there was difficulty maintaining Resident #12's INRs over 2.5. Resident #12 had been on 3 mg of warfarin daily for several weeks, but the resident's INR had dropped from 1.9 to 1.2. The resident's dose was increased to 4 mg daily. -The physician's progress note did not reveal whether the physician was aware of Resident #12's missed doses of warfarin from 2/21/25 to 2/27/25. A nurse progress note, dated 3/12/25 at 4:50 p.m., documented Resident #12's pedal (foot) pulse had diminished to the right lower extremity with spreading reddened petechiae (tiny round brown-purple spots due to bleeding under the skin) and possible hematoma (a collection of blood outside of a vessel) to the anterior ankle that had worsened per spouse and report received from the DON. The hospital was notified and informed of pending results of an arterial doppler ultrasound (a non-invasive imaging test that uses sound waves to evaluate the blood flow in the arteries of your arms and legs) performed on 3/12/25 and the nurse practitioner (NP) gave an order for Resident #12 to be transferred to the hospital to rule out a possible arterial occlusion. A nurse progress note, dated 3/12/25 at 8:25 p.m., documented the facility was alerted to critical imaging results of the arterial doppler which was performed on 3/12/25 at the facility, prior to Resident #12's hospitalization. The hospital was contacted and alerted to the critical results and the information was faxed to the emergency department. Resident #12's hospitalization record was provided by NHA #1 on 4/4/25 at 10:33 a.m. The hospital records revealed the documented admission diagnosis for Resident #12 on 3/13/25 was atherosclerosis (build up caused narrowing and reduced blood flow) of the native artery of the right lower extremity with rest pain (pain when resting). Resident #12 underwent a right above the knee amputation during his hospitalization on 3/18/25. A physician's progress note, dated 4/3/25 at 12:37 p.m., documented Resident #12 was extensively discussed at QAPI on 3/18/25. The resident's diagnosis was ASVD (atherosclerotic vascular disease) of the right leg arteries with rest pain (pain when resting) which suggested chronic ischemia/arterial insufficiency. -However, the physician's progress note was not written until 4/3/25, during the survey (over two weeks after the 3/18/25 QAPI meeting). A review of anticoagulant medication administration for Resident #12 from 3/21/25 to 4/3/25 revealed the resident had received all of his warfarin doses as ordered and the facility was monitoring for other residents receiving warfarin, per the facility's corrective action plan. VI. Staff interviews The medical director (MD) was interviewed on 4/3/25 at 4:35 p.m. The MD said Resident #12's ultrasound result, prior to his hospitalization on 3/12/25, revealed an occlusion (blockage) of the right popliteal artery (blood vessel located behind the knee). The MD said he was aware of Resident #12's missed warfarin doses. He said the occlusion was probably chronic (longstanding) and he wrote a statement on 4/3/25 (during the survey) regarding this opinion. He said the only way to know with certainty the cause of the occlusion would be to review the information in the pathology report of Resident #12's above the knee amputated (AKA) leg, which would have shown if the condition were chronic or not. The MD said he was unable to obtain Resident #12's pathology report at the time of interview. The physician (PHY) was interviewed on 4/3/25 at 4:50 p.m. The PHY said though his name was entered by the nursing staff on the physician orders, the physician's orders placed on 2/27/25 were likely provided by an on-call provider. The PHY said the facility had a history of serious issues with warfarin management. The PHY said he did not think physician's orders were being entered properly by nursing staff all of the time. The PHY said there was a situation for another resident in which an INR was reported and the physician communicated the orders, however the orders were not implemented for a few days. The PHY said he had conveyed the importance of the process for warfarin orders with the facility. The PHY said the facility had provided education to staff since Resident #12's incident and he was also taking an active role to ensure the process was being followed. The clinical resource person (CRP) was interviewed on 4/3/25 at 4:58 p.m. The CRP said Resident #12 had missed warfarin administration doses for five consecutive days. The CRP then reviewed documentation in Resident #12's EMR (during the interview) and said she did not find any warfarin doses given from 2/21/25 to 2/27/25, for seven days. Registered nurse (RN) #1 was interviewed on 4/3/25 at 6:38 p.m. RN #1 said she reported Resident #12's INR result from 2/20/25. RN #1 said she received verbal orders from the physician. She said Resident #12 received a one-time dose of warfarin 4 mg on 2/20/25 and then was supposed to receive daily warfarin 3.5 mg to begin on 2/21/25 with a recheck of his INR level on 2/26/25. RN #1 said she entered the information on Resident #12's INR flow sheet and thought she had entered the physician's order for daily warfarin into the EMR, however, she said when the DON later asked her about Resident #12's missed warfarin doses, she was not able to find any physician's order in the EMR for the daily warfarin doses which were to begin on 2/21/25. RN #1 said it was important to monitor INR levels for residents on anticoagulants to maintain a therapeutic level of the medication. RN #1 said she was reeducated about transcription of medication orders, including the importance of documenting physician's orders into the EMR. RN #2 was interviewed on 4/3/25 at 9:40 p.m. RN #2 said if he received physician's orders for warfarin, he would place the order in the resident's EMR immediately and would expect the dose of the medication to be adjusted as needed, based upon the resident's INR levels. RN #3 was interviewed on 4/3/25 at 9:44 p.m. RN #3 said if she received physician's orders for medications, she would enter the orders in the resident's EMR at the time the order was received. Licensed practical nurse (LPN) #3 was interviewed on 4/7/25 at 9:35 a.m. LPN #3 said the facility provided nursing staff education a few weeks ago to ensure no missed doses of warfarin for the residents. LPN #3 said the education included the correct process for taking and entering physician's orders. LPN #3 said residents who missed doses of anticoagulant medications could develop blood clots and this could be life threatening. RN #1 was interviewed again on 4/7/25 at 9:50 a.m. RN #1 said if residents did not receive their anticoagulant medication as ordered, they could develop a blood clot, pulmonary embolism (a blot clot in the lungs) or a stroke. LPN #2 was interviewed on 4/7/25 at 10:10 a.m. LPN #2 said the physicians wanted Resident #12's INR level to be between 2.5 to 3.5. LPN #2 said she reviewed Resident #12's EMR for lab results and orders on 2/27/25 and she noticed his INR was very low (0.97). LPN #2 said Resident #12's EMR also had no physician's orders for warfarin since 2/20/25. LPN #2 said Resident #12's anticoagulant therapy flow sheet revealed he was supposed to receive warfarin 3.5 mg daily beginning on 2/21/25. LPN #2 said the process for anticoagulant therapy included receipt of INR result, reporting of the result to the physician, information entered on the anticoagulant flow sheet with the INR result and new physician's orders, physician's orders entered in the EMR and a progress note entered about the process that was followed. LPN #2 said she contacted the DON and the physician when she realized Resident #12 had not received the warfarin as ordered. LPN #2 said Resident #12 was at risk of getting blood clots. She said residents could get blood clots if warfarin was not given as ordered. LPN #2 said the facility provided education to nursing staff after this incident, which included reporting of INR results, receipt of physician's orders, using the INR flow sheet and the importance of entering physician's orders for warfarin in the EMR. LPN #1 was interviewed on 4/7/25 at 10:34 a.m. LPN #1, who was also a unit manager, said she assisted the staff development coordinator with education the education that was provided to staff after Resident #12 was transferred to the hospital on 3/12/25. She said staff education included the importance of calling physicians with lab results, obtaining physician's orders, entering pertinent information on the INR flow sheet and entering the new physician's orders in the EMR. LPN #1 said she knew Resident #12 had missed doses of warfarin, but she did not know details or the extent of the missed doses until 3/10/25 when LPN #2 asked her to look at Resident #12's right lower leg, which had new redness. She said there were petechiae of Resident #12's right ankle measuring approximately three centimeters (cm) by six cm. LPN #1 said there was another area on top of the right foot with a hematoma which had the same measurement. LPN #1 said she received physician's orders for an ultrasound of Resident #12's right leg and she placed the orders in the EMR. DON #1 was interviewed on 4/7/25 at 10:59 a.m. DON #1 said LPN #2 reported Resident #12's missed doses of warfarin to her early in the morning of 2/27/25. She said they identified this as a medication error, notified the physician and received an order for an INR. She said the provider did not want to place an order at the time, as the facility expected providers to visit Resident #12 that day. She said a physician did not see Resident #12 that day and there was a delayed receipt of warfarin orders for Resident #12. -Resident #12 did not receive a new physician's order for warfarin until 2/27/25 at 10:25 p.m. and the warfarin dose was not administered until 2/28/25 at 12:10 a.m. DON #1 said she reported Resident #12's missed doses of warfarin to NHA #1 and suspended RN #1 on 2/27/25. DON #1 was interviewed again on 4/7/25 at 12:15 p.m. DON #1 said she did not know why there was not a physician's order for resumption of Resident #12's warfarin or why the medication was not given until 16 hours after LPN #2 discovered the missed doses. DON #1 said staff should have recognized prior to 2/27/25 that Resident #12 had not received warfarin doses. DON #1 said nurse staff education did not begin until 3/13/25, the day after Resident #12 was sent to the hospital with a blood clot. She said staff education (in addition to education for RN #1) should have begun when the medication error was initially discovered on 2/27/25, as staff did not recognize the missed warfarin doses for seven days. The pharmacist ([NAME]) was interviewed on 4/7/25 at 2:10 p.m. The [NAME] said Resident #12's INR should be between 2.5 to 3.5 for his condition. The [NAME] said the missed warfarin doses contributed to his decreased INR, which increased the chance of clotting, and any clots could increase the risk for amputation. The [NAME] said the anticoagulant policy would show the strategy to increase the INR to a therapeutic level. The [NAME] said if doses were missed, he would give a warfarin dose immediately and possibly a bolus dose (a one-time larger dose). The [NAME] said after missed doses of warfarin, the goal was to return the resident to a therapeutic INR range as quickly as possible. The [NAME] said in Resident #12's case, he would have suggested a bolus dose, possibly 10 mg. The [NAME] said this type of bolus dose was not used for Resident #12. The [NAME] said Resident #12's INR was currently back within a therapeutic range.

Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure two ceiling swamp cooler vents, two shower rooms and eight mechanical rooms were thoroughly cleaned, free from debris and did not contain any black discoloration on any surfaces. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised September 2024, was provided by the assistant director of nursing (ADON) on 10/16/24 at 12:12 p.m. The policy revealed that in accordance with residents' rights, the facility would provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This included ensuring that the resident could receive care/services safely and the physical layout of the facility maximized resident independence and did not pose a safety risk. The environment referred to any environment in the facility that was frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activity areas. The term orderly was defined as an uncluttered physical environment that was neat and well kept. The term sanitary included, but was not limited to, preventing the spread of disease-causing organisms by keeping resident care equipment clean and properly stored. Resident care equipment included but was not limited to, equipment used in the completion of the activities of daily living. Housekeeping and maintenance services would be provided as necessary to maintain a sanitary, orderly and comfortable environment. II. Observations An environmental tour of the facility was conducted on 10/16/24 at 10:00 a.m. The following observations were made: The hallway ceiling air vent (Swamp Cooler) by resident room [ROOM NUMBER] had two missing vent louvers. There was dark debris on the vent louvers and on the ceiling surrounding the vent. The hallway ceiling air vent (Swamp Cooler) by resident room [ROOM NUMBER] had dark debris on the vent/louvers and on the ceiling surrounding the vent. The ceiling adjacent to the vent had sheetrock damage and sagged (bulged) downward. The shower room on hall 300 had water-dripping from the showerhead. The ceiling exhaust vent in the shower room had no cover and contained debris. There was debris in the corners of the shower. The floor tile in the shower had a brown discoloration. There was black discoloration where the walls met the floor. There was black discoloration where the shower room walls joined in a corner. The shower room on hall 200 had water-dripping from the showerhead. The ceiling exhaust fan was non-functional. There was black discoloration where the walls met the floor. There was black discoloration where the shower room walls met in a corner. The shower floor contained a large area of black discoloration. The mechanical room on the South One hall by resident room [ROOM NUMBER] had sheet rock damage on one wall, black discolored areas on two walls and black discoloration on the floor. The air from this furnace (an appliance fired by gas, oil, or wood in which air or water was heated to be circulated throughout a building in a heating system) supplied air to resident rooms. The mechanical room on the South Two hall by resident room [ROOM NUMBER] had sheet rock damage on one wall, one water stained wall and an unkempt floor. The air from this furnace supplied air to resident rooms. The mechanical room on the South Three hall by resident room [ROOM NUMBER] had sheet rock damage on one wall and two holes in the wall by the entrance door frame. The air from this furnace supplied air to resident rooms. The mechanical room on the South Four hall by resident room [ROOM NUMBER] had numerous dead gnats on the floor and on the furnace unit. There was cracked paint on the ceiling and on three walls. The floor vent was rusty and there was sheetrock damage on one wall. There were two holes in the wall by the entrance door frame. The air from this furnace supplied air to resident rooms. The mechanical room on the North One hall by resident room [ROOM NUMBER] had sheet rock damage on three walls, an unkempt floor, an unkempt floor vent and a small water line that was leaking water into a trash can. The air from this furnace supplied air to resident rooms. The mechanical room on the North Two hall by resident room [ROOM NUMBER] had an unkempt floor and an unkempt floor vent that was bent in the middle. The air from this furnace supplied air to resident rooms. The mechanical room on the North Three hall by resident room [ROOM NUMBER] had sheet rock damage on two walls, a rusty/unkempt floor vent and black discoloration on the entire back wall. The air from this furnace supplied air to resident rooms. The mechanical room on the North Four hall by resident room [ROOM NUMBER] had sheet rock damage on two walls, one loose floor tile and an unkempt floor. The air from this furnace supplied air to resident rooms. III. Staff interviews A second environmental tour of the facility was conducted on 10/16/24 at 12:06 p.m., with the maintenance supervisor (MS), unit manager (UM) #1 and the accounts manager (AM). They agreed with the above observations. The MS, UM #1 and the AM were interviewed on 10/16/24 at 2:29 p.m. They said no residents or family members had discussed with them any issues with air quality or black discolorations in the bathrooms. They said there were no work orders for the above observations. The MS said there were work order notebooks at the two nurse's stations. The MS said the staff could fill out work orders, text him, call him or verbally tell him of any issues that needed repairs. UM #2 was interviewed on 10/16/24 at 4:57 p.m. UM #2 said a service contractor was coming to the facility tomorrow (10/17/24), to evaluate the requirements for the repairs on the North Three hall mechanical room. She said nine residents would be moved from the North Three hall for a short period so the repairs could be made to the mechanical room. UM #2 said the residents and their family members would be informed/asked about room changes and the residents would be able to move back to their rooms after the repairs had been completed. The nursing home administrator (NHA) was interviewed via a conference call on 10/16/24 at 5:25 p.m. The NHA said the facility came under new management on 10/1/24. He said approximately two weeks after that date, he was made aware that there was black discoloration in one of the mechanical rooms and he was unsure which mechanical room it was.

Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection in one out of two units. Specifically, the facility failed to: -Ensure resident rooms were cleaned in a sanitary manner; -Ensure manufacturer recommended surface contact times were followed for effective disinfection; -Ensure nebulizers (an apparatus that allows medications to be inhaled) were stored and cleaned according to professional standards of practice. Findings include: I. Housekeeping A. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures, (5/4/23), retrieved on 4/17/24 from https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html#anchor/1505929362118 included the following recommendations, documented in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Proceed from high to low to prevent dirt and microorganisms from dripping or falling and contaminating already cleaned areas. The identification of high touch surfaces and items in each patient care is a necessary prerequisite to the development of cleaning procedures. Common high touch surfaces include: bed rails, IV poles, sink handles, bedside tables, counters where medications and supplies are prepared, edges of privacy curtains, patient monitoring equipment, transport equipment, call bells, doorknobs and light switches. The CDC Best Practices for Environmental Cleaning in Healthcare Facilities, last reviewed in 2023, retrieved on 4/17/24 from https://www.cdc.gov/hai/pdfs/resource-limited/environmental-cleaning-RLS-H.pdf included the following recommendations, If manufacturer's instructions are not available, use this general process to manually reprocess reusable supplies, equipment and personal protective equipment (PPE): 1. Immerse in detergent solution and use mechanical action (scrubbing) to remove soil, 2. Disinfect by fully immersing items in boiling water or fully immersing the items in disinfectant solution for the required contact time and rinsing with clean water to remove residue. B. Manufacturer's recommendations According to the Ecolab Peroxide Multi Surface Cleaner and Disinfectant manufacturer guidelines, last updated in 2023, retrieved on 4/17/24 from https://www.ecolab.com/offerings/all-purpose-cleaning/rapid-multi-surface-disinfectant-cleaner included the following recommendations, This EPA (Environmental Protection Agency) registered product disinfects in three to five minutes with hospital disinfection claims. C. Observations 1. Housekeeper (HSK) #1 cleaned room [ROOM NUMBER] on 4/11/24 at 11:40 a.m. HSK #1 performed hand hygiene and put on gloves. She obtained a wet washcloth out of disinfectant solution and wiped the top of the bedside table. The surface did not remain wet for three minutes. She then disposed of the washcloth into the used linen receptacle on the housekeeper cart. -HSK #1 failed to ensure the surface of the bedside table remained wet for the three minute surface disinfectant time. HSK #1 performed hand hygiene and put on new gloves. She obtained a wet washcloth out of the disinfectant solution and wiped off the top of the sink and the vanity counter. She disposed of the washcloth into the linen receptacle on the housekeeper cart. -The surface of the sink and vanity was not visibly wet for the three minute surface disinfectant time. HSK #1 performed hand hygiene and put on new gloves. She obtained the toilet brush that was in a toilet brush holder from the housekeeping cart and cleaned the inside of the toilet bowl before returning the toilet brush to the toilet brush holder and placing it into a separate compartment in the housekeeping cart. -The toilet brush was not sanitized after it was used and HSK #1 did not use a chemical to sanitize the toilet. -HSK #1 failed to spray disinfectant cleaner into the toilet bowl prior to cleaning inside the toilet bowl. HSK #1 performed hand hygiene and put on new gloves. She got a new washcloth out of the disinfectant solution. She wiped down the top of the toilet seat and then wiped underneath the toilet seat. She then wiped the top of the toilet bowl and continued with the same washcloth back up to the toilet seat. -The surface of the toilet did not remain visibly wet for the three minute surface disinfectant time. -HSK #1 failed to change gloves, perform hand hygiene and dispose of washcloth after wiping a dirty area and before wiping a clean area. HSK #1 performed hand hygiene and put on new gloves before wiping the vanity mirror. HSK #1 said she was finished cleaning the room and moved to the next room to clean. -HSK #1 failed to wipe the high touch surface areas in the room, including the call light, bed controls and door handles. D. Staff interviews HSK #1 was interviewed on 4/11/24 at 12:00 p.m. HSK #1 said the facility used Ecolab Multi Surface Disinfectant Cleaner to clean the surfaces in the rooms, including the bathroom. She said the chemical required a three minute disinfection time. She said once she wiped surfaces with the towel that was soaked in the chemical, the surface area could not be wiped off for three minutes. She said she did not know the surface had to be visibly wet for at least three minutes. HSK #1 said areas of the resident's room and bathroom needed to be cleaned from a high area to a low area. She said high touch surfaces should also be cleaned. She said she did not disinfect the toilet brush after use but returned it to its designated receptacle in the housekeeping cart. The housekeeping supervisor (HSKS) was interviewed on 4/11/24 at 12:00 p.m. The HSKS said surfaces should be cleaned from high reach to low reach areas and surfaces that had already been cleaned should not be wiped with a rag that had cleaned a dirty surface. She said high touch areas, such as door knobs and call lights, should be cleaned during the room cleaning process. The HSKS said surfaces needed to remain wet with the Ecolab Multi Surface Disinfectant Cleaner for the full three minutes to properly disinfect the surface. She said the toilet brush was not routinely cleaned after every resident room. 43950 II. Failure to ensure proper infection control practices were followed for resident-care items and equipment A. Facility policy and procedure The Cleaning and Disinfection of Resident-Care Items and Equipment policy, revised September 2022, was provided by the quality mentor (QM) on 4/9/24 at 8:15 p.m. It read in pertinent part, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (center of disease control) recommendations for disinfection and the OSHA (occupational safety and health administration) pathogens standard. B. Observations Resident #7 was observed in her room on 4/8/24 at 12:46 p.m. The resident's nebulizer unit, including mouthpiece, T-piece, and tubing was on the bed. The mouthpiece and T-piece were a carmel color. -The nebulizer mouthpiece was touching the bed surface and was not stored in a sanitary manner. Resident #7 was observed in her room on 4/9/24 at 12:08 p.m. The resident's nebulizer unit including mouthpiece, T-piece, and tubing was on the floor, by the oxygen unit, and partially under the bed. -The unit and mouthpiece were dusty and carmel colored. -The nebulizer was on the ground with the mouthpiece on top of it. The nebulizer and mouthpiece were not stored in a sanitary manner. C. Record Review Review of the April 2024 computerized physician orders (CPO) revealed Resident #7 had an active order for nebulizer treatments and utilized the nebulizer two times per day. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/9/24 at 12:10 p.m. LPN #2 said she knew nebulizer treatments were used to inhale medication into the lungs. LPN #2 said when a nebulizer unit was not in use it was stored in the nurses cart. LPN #2 said sometimes the nebulizers are stored in the residents room on a bedside stand so that it's more easily accessible. LPN #2 viewed Resident #7's nebulizer unit on the floor and said it would not be okay to store the nebulizer on the floor because it was used to aerosol directly into the lungs and could cause dust to contaminate the resident's lungs. The director of nursing (DON) and infection preventionist (IP) were interviewed on 4/9/24 at 12:20 p.m. The DON said the unit should be stored on a table, in a bag. The DON and IP viewed Resident #7's nebulizer unit stored on the floor including the mouthpiece, T-piece, and tubing and said it should not be on the floor. The IP and DON said it was an infection control problem. The DON said she would start nursing education regarding proper storage of nebulizer equipment immediately.

Based on record review and interviews, the facility failed to ensure level II preadmission screening and resident review (PASRR) were completed for one (#33) of two residents out of 32 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional and psychosocial well-being. Specifically, the facility failed to follow PASRR level II recommendations for Resident #33. Findings include: I. Facility policy and procedure The PASRR completion policy, revised 2/23/24, was provided by the quality mentor (QM) on 4/11/24 at 11:40 p.m. It read in pertinent part, If the resident has a PASRR Level II, the community is responsible for ensuring that any recommendations from the PASRR Level II are implemented and care planned for the resident. II. Resident status Resident #33, age above 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included history of falling, weakness, generalized anxiety disorder, major depressive disorder, recurrent, mild, unspecified symptoms and signs involving cognitive functions and awareness. The 1/13/24 minimum data set (MDS) assessment did not document the resident's level II PASRR level II for a serious mental illness. It revealed that the resident had severe cognitive impairments with a brief interview of mental status (BIMS) score of five out of 15. III. Record review Review of the resident's PASRR level II dated 10/21/22 documented the resident had cognitive deficits that were very present during the meeting with the evaluator. The evaluator concluded that cognitive decline appeared to be the primary issue from the observations and assessment. Resident #6 did not have a history of mental health services or behavioral health support services. The evaluator noted a primary diagnosis of unspecified neurocognitive disorder and recommended formal neuropsychological testing to understand the cause or other processes that were causing cognitive declines -Review of the comprehensive care plan dated 2/22/24 did not document the resident's PASRR level II screening and specialized services recommendations for mental illness. The social services progress notes reviewed from 10/21/22 through 4/11/24 did not document that the facility had reached out to a mental health provider to establish services for neuropsychological testing. Review of the April 2024 CPO failed to show an order for the resident to be seen for neuropsychological testing. IV. Staff interviews The social services director (SSD) was interviewed on 4/11/24 at 10:54 a.m. The SSD said the PASRR recommendations were not followed up on according to her review of the medical record. She said neuropsychological testing was not completed because there had been issues with the behavioral health provider that the facility had worked with, however, the behavioral health facility that the facility worked with did not conduct neuropsychological testing. She said she did not know why there was not a physician's order for neuropsychological testing. She said she would audit all resident PASRRs and ensure all recommendations were followed and maintain a spreadsheet to track PASRRs due and follow up on all recommendations. The director of nursing (DON) was interviewed on 4/11/24 at 11:45 a.m. The DON said the facility should follow up on all PASRR recommendations to ensure residents maintained their quality of life. The nursing home administrator (NHA) was interviewed on 4/11/24 at 11:45 a.m. She said education, training and audits would be put in place to ensure the facility maintained tracking of PASRR evaluation completion and follow up on recommendations.

Based on observations, record review and interviews, the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for one (#31) of two residents out of 32 sample residents. Specifically, the facility failed to provide eating assistance for a resident who required supervision and cueing and who was at high risk for weight loss. Finding include: I. Facility policy and procedure The Weight Management policy and procedure, reviewed 2/29/24, was provided by the quality mentor (QM) on 4/11/24 at 11:39 a.m. It read in pertinent part, Residents are monitored for weight change on a regular basis. Results are reviewed and analyzed by the facility for interventions as appropriate. Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, registered dietician (RD) evaluation and assisted dining. II. Resident #31 A. Resident status Resident #31, age 82, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease and severe protein malnutrition. The 1/2/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with deficits in short and long term memory according to the staff interview for mental status. She was dependent on staff for toileting and personal hygiene. She required substantial/maximal assistance with bed mobility, transfers and required supervision with touch assistance and cueing for eating. B. Observations During a continuous observation on 4/8/24, beginning at 11:40 a.m. and ending at 12:30 p.m., Resident #31 was sitting in the dining room in a wheelchair at a table alone. At 12:00 p.m. Resident #31 was served her meal which included pureed meat, vegetables and mashed potatoes. She was also served ice cream and a whole banana. The staff uncovered the resident's plate, opened the ice cream up and peeled the banana. The staff then went to assist other residents. At 12:05 p.m. Resident #31 picked up her fork and used the fork to pick at what was on the plate. She ate one to two small mouthfuls of meat and vegetables. She then began to eat the ice cream and finished the ice cream. -Staff were not observed assisting or cueing the resident with eating. At 12:30 Resident #31 remained in the dining room. She had consumed all of the ice cream. She had not eaten her meal or the banana. Staff assisted Resident #31 back to her room. -Staff did not ask Resident #31 if she was still hungry or attempt to offer the resident a bite of food prior to taking the resident back to her room. -Staff did not offer an alternative to the resident when she did not eat the food on the plate in front of her. During a continuous observation on 4/10/24, beginning at 12:00 p.m. and ending at 12:40 p.m., Resident #31 was again sitting in the dining room in a wheelchair. At 12:18 p.m. Resident #31 was served a plate that contained pureed meat, vegetable and mashed potatoes. She was also served a cup of ice cream and a peeled banana.The staff uncovered the resident's plate and opened the ice cream. The staff then went to assist other residents. At 12:20 Resident #31 picked up a spoon and started eating the ice cream. Resident #31 did not eat any of the pureed meat, pureed vegetables, mashed potatoes or banana. -The staff did not assist or cue the resident with her meal. At 12:40 p.m. Resident #31 finished the ice cream. Resident #31 did not take any bites of the pureed meat, pureed vegetables, mashed potatoes or banana. -The staff did not attempt to assist or cue the resident with her meal. -The staff did not offer the resident any food alternatives or additional food items when the resident did not eat the food on the plate in front of her. C. Record review The nutrition care plan, initiated 3/13/23 revised 9/12/23, indicated Resident #31 was at an increased nutritional risk related to Alzheimer's disease and severe protein calorie malnutrition. The interventions included monitoring and reporting signs of dysphagia (inability to swallow), monitoring signs of malnutrition (muscle wasting, significant weight loss), offering preferred foods, offering snacks, encouraging the resident to request large portions of foods she enjoyed and encouraging juice and milk with meals for added calories. The functional abilities/self care care plan, initiated 3/16/23 and revised 3/28/24, indicated Resident #31 had a decline in self care function related to Alzheimer's disease and rheumatoid arthritis. The interventions included providing set-up assistance and clean-up assistance for meals. -A review of the comprehensive care plan did not reveal the care plan had been updated to include the resident's increased need for feeding assistance. A comprehensive review of meal assistance documentation for Resident #31 revealed inconsistent eating assistance. The meal assistance documentation record from 3/8/24 to 4/8/24 revealed she required set up assistance 24 times, required supervision/touch assistance/cueing four times, required partial/moderate assistance two times, was dependent two times and not applicable eight times. -There was nothing documented on the record for meal assistance 47 times from 3/8/24 to 4/8/24. III. Staff interviews The registered dietitian (RD) was interviewed on 4/11/24 at 10:11 a.m. The RD said she had noticed Resident #31 recently needed more supervision, encouragement and cueing for her oral intake during meals. She said Resident #31 was at high risk for weight loss and had recently lost weight, even though overall weight was trending up. She said the staff should have encouraged oral intake during meals. Certified nurse aide (CNA) #1 was interviewed on 4/11/24 at 10:56 a.m. CNA #1 said staff assisted with just the set up of Resident #31's meal tray. She said staff did not provide assistance or cueing for Resident #31 at meals. She said Resident #31 was able to feed herself. CNA #1 said Resident #31 would only eat, at most, 25% of her meal. She said any feeding assistance required should be documented in the electronic medical record point of care system. She said residents who were at risk for weight loss should be cued and assisted with their meals and it should be documented every meal. The director of nursing (DON) was interviewed on 4/11/24 at 12:00 p.m. The DON said a resident that required supervision and cueing, especially resident's at risk for weight loss should have received assistance in the resident dining room. She said Resident #31 should have received staff cueing and supervision during her meals.

Based on record review and interviews, the facility failed to ensure two (#35 and #51) out of two residents out of 32 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Follow hospital physician orders to remove Resident #35's cervical neck brace after six weeks; -Monitor the skin under Resident #35's cervical neck brace; -Ensure Resident #35 was transported to and attended her neuro-orthopedic doctor' s appointment; and, -Support and position Resident #51 in her wheelchair properly. Findings include: I. Professional reference The Hull University Hospital Guide to Wearing Your Cervical Hard Collar, dated 3/19/21, was retrieved from https://www.hey.nhs.uk/patient-leaflet/guide-wearing-cervical-hard-collar/ on 4/16/24. It read in pertinent part, A hard collar is a device designed to limit movement of your neck. It is most commonly used to manage spinal fractures. It is important the collar is removed daily to be able to wash, dry and check your skin. However, when you no longer require your collar you will be advised to gradually remove it and you will be provided with an exercise program to strengthen your muscles again. II. Resident #35 A. Resident status Resident #35, over the age of 65, was admitted on [DATE] and readmitted [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included fracture of second and fourth cervical vertebra (neck fracture), rhabdomyolysis (damaged muscles), congestive heart failure, and history of falling. The 2/16/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. She required substantial/maximal assistance with lower body dressing and partial/moderate assistance for toileting, bathing, upper body dressing, and bed mobility. Transfers required supervision or touch assistance and walking 10 feet once standing. B. Resident interview and observation Resident #35 was interviewed on 4/8/24 at 1:50 p.m. Resident #35 said he said she had fallen at home in January 2024 and fractured her neck. She was observed wearing a rigid cervical neck brace. Resident #35 was observed on 4/10/24 at 7:28 a.m. She was seated in her wheelchair in the dining room with her rigid cervical neck brace on. Resident #35 was interviewed again on 4/11/24 at 10:34 a.m. She said her rigid cervical neck brace was uncomfortable but was told not to take it off at all. Resident #35 said she did not know the date of when she could remove it. Resident #35 said the neck brace did not feel very good and it was difficult to sleep with the neck brace due to it being hard. Resident #35 said she had no pain at rest but if she moved she had moderate pain. The neck brace padding around her chin and neck was stained with brown and yellow marks. -Resident #35 began wearing the rigid cervical neck brace on 1/21/24. She had been wearing the brace for 12 weeks. C. Record review The hospital discharge documents (admitted to hospital 1/14/24 and discharged [DATE]) revealed instructions from the doctor in pertienent part, You will need to wear a cervical collar at all times for six weeks. You will have another collar for showers only. -However, these orders were never entered into the facility orders upon the resident' s admission. Facility nurse practitioner (NP) #1' s new admission note, dated 1/22/24, revealed the reason for the appointment was the resident was status post acute hospitalization for a fall resulting in cervical fractures. The assessment and plan documented the resident was neurologically intact, the fractures were stable and there were no ligamentous injuries. The neurosurgeon recommended conservative management with a rigid collar. Aspen cervical collar was to be worn at all times for six weeks. Follow-up with neurosurgery as instructed. -However no physician orders were entered into the facility orders to confirm the cervical collar was to be worn for six weeks. The physical therapy (PT) evaluation dated 1/22/24 revealed the resident was recently hospitalized following a fall and hitting the back of her head. The resident was diagnosed with C2 and C4 (second and fourth cervical vertebra) fractures which were treated conservatively with a cervical collar for six weeks. The cervical collar was to be worn at all times. -The PT was aware Resident #35 was to wear the cervical collar for six weeks but did not take steps to ensure the facility had physician orders in place to notify the staff when the cervical could be removed after the six week time frame. The occupational therapy (OT) evaluation, dated 1/22/24, revealed the resident was recently hospitalized following a fall and hitting the back of her head. She was diagnosed with C2 and C4 fractures and was treated conservatively with a cervical collar for six weeks at all times. -The OT was aware Resident #35 was to wear the cervical for six weeks but did not take steps to ensure the facility had physician orders in place to notify the staff when the cervical collar could be removed after the six week time frame. The musculoskeletal care plan, initiated 1/28/24, revealed the resident had alteration in status related to fractures of the second and fourth cervical vertebra. The resident wore a rigid cervical collar at all times. Interventions included: assisting the resident with the use of supportive devices (rigid c-collar) as recommended, analgesics (pain medications) as ordered by the physician, monitor and documenting for side effects and effectiveness of pain medications, monitoring and documenting for risk of falls, educating the resident/family/caregivers on safety measures that need to be taken in order to reduce a risk of falls. -However, the care plan failed to identify how long the resident was supposed to wear the brace, how to clean the brace and showering precautions. The April 2024 CPO revealed the following physician orders: Bathing every day shift every Monday and Thursday, order date 1/23/24. -However, the physician's order did not include the use of a special shower collar during showers. Skin monitoring: remove the cervical collar at bedtime to assess skin for any breakdown, then reapply cervical collar, ordered on 2/23/24. -However, the resident was admitted on [DATE] and there was no documentation indicating skin monitoring had been completed under her cervical collar for 33 days. Cervical collar in place at all times. Monitor placement every shift. Cervical collar to be re-evaluated by neurosurgeon at appointment on 3/28/24, order date 3/25/24. -However, the order was added two months after the resident was admitted and the facility failed to take the resident to her scheduled neurosurgeon appointment. Cervical (neck) X-ray, order date 4/11/24 (during the survey process). -Resident #35 had not been taken to any neuro-orthopedic appointment check-ups since admission. -The facility continued to require Resident #35 to wear her rigid cervical neck brace due to lack of follow-up. III. Staff interviews The quality mentor (QM) was interviewed on 4/10/24 at 4:10 p.m. The QM said the facility called the orthopedic office today (4/10/24) for Resident #35 but the physician' s office did not know when the hard neck brace could be removed. The QM said no one at the orthopedic office knew when Resident #35 could remove the neck brace. She said the facility did not know either. The QM said the orthopedic office confirmed that Resident #35 had had an appointment set up with them on 3/8/24 but Resident #35 did not show up for the appointment. The QM said the facility transportation department had set up the original 3/8/24 appointment but she did not know why the appointment was missed or why no one at the facility realized that she had missed the appointment. The QM said she scheduled a new appointment for 5/30/24 after it was brought to her attention that Resident #35 did not have a follow up appointment with the neurosurgeon. The QM said she called Resident #35' s orthopedic doctor but he did not answer and she had not heard back from him. The QM said Resident #35 had not seen her orthopedic doctor since she had been admitted to the facility. The QM said the orthopedic office was not able to answer any questions about Resident #35' s cervical neck brace removal date because they had never seen her as a patient. The director of nursing (DON) was interviewed on 4/11/24 at 11:05 a.m. She said the process for keeping track of casts, boots, slings and braces was to start by looking at the admission orders and to look for follow-up physician appointments. The DON said she would also look at the care plan to see if the device had a date it could be discontinued or be a permanent type of brace. The DON said she would want all the information and details on the care plan so the staff were aware of the care and treatment for the brace. The DON said a physician' s order would need to be obtained for the device to have a start and end date. She said physician orders needed to be included for medical appointments that included the date and time. The DON reviewed the hospital discharge orders for Resident #35 and said the hospital physician documented the cervical collar needed to be worn at all times for six weeks. She said the hospital discharge information also documented the resident would have another collar to wear during showers. The DON said the duration of the cervical collar and the guidance for the shower collar should have been documented as a physician order and in the resident' s plan of care. The DON said if the physician order was in the resident' s medical record it would have triggered the nurses to call the physician for confirmation when the six weeks was completed. The DON said the hospital discharge orders were not entered into the resident' s medical records correctly regarding the cervical collar and removal after six weeks. She did not know the resident had a collar to wear during the showers but would find out more information. The DON said the admission nurse did not confirm the orders. The DON said the admission nurse did not make the follow-up appointment. The DON said she would complete an audit of all residents that had a cast, boot, sling or brace. The QM was interviewed again on 4/11/24 at 11:43 a.m. She said the facility NP had ordered a cervical x-ray and planned to send the results to the orthopedic physician in hopes he would be able to make a decision about when the rigid cervical collar should be removed for Resident #35. The QM said she had called the resident' s physician yesterday (4/10/24) regarding the cervical neck collar but he never called her back. The QM said Resident #35 had never been a patient of this physician before. The QM said she was not sure which physician had written the discharge orders from the hospital for wearing the cervical collar for six weeks. The QM said she was unsure why the facility did not follow up with the transportation company when they did not take Resident #35 to her appointment on 3/8/24. She said the facility should have followed up after the resident missed her appointment and scheduled a new appointment for the resident. The admissions specialist (AS) was interviewed on 4/11/24 at 1:29 p.m. The AS said the transportation driver (TD) had been out sick. The AS said he helped with transportation at times. The AS said the TD did all of the scheduling for medical appointments and drove the residents to their appointments. The AS said the TD had arranged for an outside transportation company to transport the resident to her appointment on 3/8/24. The AS said he was not sure why the transportation company did not take her. The AS said the facility should have documented what happened but there was no documentation or follow-up. III. Facility follow-up The QM provided the transportation education information on 4/11/24 at 3:27 p.m. It revealed, residents often require medical appointments at outside clinics and specialists. It was the responsibility of the facility to ensure these appointments were kept and transportation was arranged to safely deliver residents to and from appointments as indicated. If a resident was deemed unsafe to attend an appointment unsupervised, the facility must arrange for an escort.Transportation schedules would be posted on the communication tab of the electronic medical system for nursing staff to access. Please communicate all transportation needs with management in a timely manner to avoid delay. Any documentation form a resident appointment should be provided to medical records to have uploaded into the resident record. If the resident misses an appointment for any reason, transportation should be notified to reschedule the appointment and the resident/resident representative should be notified. The education was signed by 22 staff members on 4/10/24. 47350 IV. Resident #51 A. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, revised May 2013, was provided by the QM on 4/11/24 at 11:39 a.m. It read in pertinent part, Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to range of motion (ROM) and mobility, including: pain, skin integrity issues, muscle wasting and atrophy, gait and balance issues, contractures or other complications that could cause or contribute to immobility, impaired ROM or injury from falls. During the resident's assessment, the nurse will identify the underlying factor that contribute to his or her ROM or mobility problems, including: immobilization (bedfast, chair or wheelchair usage), neurological conditions, conditions in which movement may lead to pain or conditions that limit or immobilize movement of limbs or digits. V. Resident #51 Resident #51, age less than 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included anoxic brain damage, heroin overdose and contractures bilateral upper extremities. The 3/15/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent with eating, toileting, personal hygiene, bed mobility and transfers. C. Observations On 4/8/24 at 12:00 p.m. Resident #51 was sitting in the dining room in a wheelchair leaning over her wheelchair to the left side. Staff was feeding the resident while the resident was slouched over the left side of her wheelchair. Staff did not offer or attempt to reposition the resident upright prior to assisting the resident with her meals. On 4/9/24 at 12:30 p.m. Resident #51 was sitting in the dining room in a wheelchair leaning over her wheelchair on the left side. Staff did not offer or attempt to reposition the resident upright prior to assisting the resident with her meal. D. Resident interview Resident #51 was interviewed on 4/9/24 at 9:00 a.m. Resident #51 said she was leaning to the side in her wheelchair. She said staff picked her up by her pants to help reposition her in her wheelchair. She said they had not assessed her positioning in the wheelchair she had since she had received it more than a year ago. E. Record review The functional abilities/self care/mobility care plan, initiated on 5/3/22 and revised on 3/14/24, indicated Resident #51 had a self care/mobility deficit and required total care related to her history of an overdose and a motor vehicle accident. Interventions included she was wheelchair dependent and required a mechanical lift for transfers and physical and occupational evaluation and treatment per physician orders. The fall care plan, initiated 2/10/22 revised 7/14/22, indicated Resident #51 was at risk for falls related to her total dependence on care and contractures. Interventions included physical therapy to evaluate and provide treatment as ordered or as necessary and the resident was awaiting a new personal adaptive wheelchair on 10/24/22. -A review of the resident's medical record did not reveal an assessment of the resident's wheelchair positioning had not been completed in the past year. F. Staff interviews The director of rehabilitation (DOR) was interviewed on 4/10/24 at 9:30 a.m. The DOR said Resident #51 received a new personal adaptive wheelchair more than a year ago. He said he was not aware of any issues and had not received any concerns from staff regarding her positioning in the wheelchair. He said her new wheelchair had not been evaluated for positioning since she had received it. He said since he observed her current positioning leaning to the left in the wheelchair, he would get an order to evaluate her wheelchair. He said this should be done to help keep the resident in the correct alignment. Registered nurse (RN) #2 was interviewed on 4/11/24 at 10:45 a.m. RN #2 said she knew Resident #51 well and she had noticed that she had been leaning to one side in her wheelchair. She said Resident #51 had her current wheelchair for over a year. She said she did not think it had been evaluated for positioning. She said the issue had been informally discussed but it had not been brought to the attention of therapy for the wheelchair to be evaluated. She said this should be done to help minimize potential issues with incorrect positioning in the wheelchair, such as skin or feeding issues. The director of nursing (DON) was interviewed on 4/11/24 at 2:00 p.m. She said dependent residents that were wheelchair bound and had positioning issues should be evaluated by therapy for positioning. She said if staff noticed positioning issues with Resident #51 in her wheelchair, the concerns should have been addressed with therapy.

Based on observations, record review and interviews, the facility failed to ensure two (#33 and #35) of two residents reviewed for accidents out of 32 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to: -Complete a root cause analysis and implement person centered fall interventions for Resident #33 and Resident #35; and, -Ensure a registered nurse (RN) completed an assessment after Resident #33 sustained a fall. Findings include: I. Facility policy and procedure The Fall management policy and procedure, revised 2/29/24, was provided by the quality mentor (QM) on 4/11/24 at 11:39 a.m. it read in pertinent part, A fall reduction program will be established and maintained, to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Please note interventions are to be re-evaluated when a resident falls for efficacy. Assess the environment and make appropriate changes, bed in lowest position, placement of furniture, lighting, personal items within reach, non-slip footwear, night light, walker, wheelchair within reach if applicable. The call light and fluids should be within reach of the resident. Positioning devices (low bed, fall mat, defined perimeter mattress). Complete a thorough analysis of fall - time of day, location of fall, causative factors. Identify whether the interventions were in place at the time of the fall. Interview staff and resident(s) if able to identify potential causative factors. II. Resident #33 A. Resident status Resident #33, over the age 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included history of falling, weakness, generalized anxiety disorder, major depressive disorder, recurrent, mild, unspecified symptoms and signs involving cognitive functions and awareness. According to the 1/13/24 minimum data set (MDS) assessment, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five of 15. The resident suffered two falls, both with injury since the previous quarterly assessment. The resident was independent with most activities of daily living (ADL). She required supervision from one person for locomotion on and off the unit. The resident required a walker for mobility. B. Observations On 4/10/24 at 8:48 a.m. Resident #33 was lying on her bed with her eyes closed. Her call light was behind the bed on the floor and not within reach of the resident.The resident did not have non-skid socks on her feet. The resident's socks were on the floor near the end of the bed. C. Record review The fall care plan, initiated on 10/20/22 and revised 4/8/24, revealed the resident was at risk for falls related to gait and balance problems and vision and hearing problems. The interventions included: ensuring the resident wore appropriate footwear when ambulating or mobilizing in a wheelchair (10/20/22), ensuring the call light was within reach (11/10/22), encouraging the resident to use the call light when she needed assistance (11/10/22), ensuring the resident had a safe environment with floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, ensuring the bed is in a low position at night; ensuring there were handrails on the walls (11/10/22), ensuring personal items within reach (11/10/22), encouraging the resident to wear non-skid socks (3/6/24) and providing frequent rounding. conducting a room air study to reduce risk of falling with oxygen tubing (12/12/23). The care plan revealed the resident chose not to use call light (12/4/23). The 12/26/23 provider progress note documented to expect unavoidable falls due to the residents' underlying comorbidities. -However, the facility failed to determine a root cause analysis of the resident's falls to implement person centered fall interventions to prevent further falls. The 4/12/23 fall risk assessment revealed the resident was at high risk for falls. 1. Fall incident on 3/16/24 - unwitnessed The 3/16/24 nursing progress note documented by a licensed practical nurse (LPN) at 5:01 p.m. revealed the resident was assessed with no noted injuries. A neurological exam was completed and was within normal limits. The residents' vital signs were within normal limits. The resident's primary care physician, power of attorney, and the director of nursing (DON) were notified of the fall. Neurological checks were initiated per facility protocol. The 3/16/24 nursing progress note documented by a LPN revealed the resident was found on her back on the floor in her bedroom. The resident said she was trying to self transfer and fell to the floor. -The facility failed to conduct a root cause analysis of the resident's fall to determine a person centered fall interventions. -A review of the resident's comprehensive care plan did not reveal the care plan was updated with person-centered fall interventions after she sustained a fall on 3/16/24. -A review of the resident's medical record did not reveal the resident was assessed by a RN after sustaining an unwitnessed fall on 3/16/24. 2. Fall incident on 4/5/24 - unwitnessed The 4/5/24 nursing progress note documented by a LPN at 9:32 p.m. revealed the resident had an unwitnessed fall. Resident 33's roommate alerted the staff that the resident had fallen. Resident #33 was found lying on her right side. The nurse assessed and there was no apparent injury. The resident was confused and unsure how she fell . The resident was assisted back to bed. The on-call provider, the resident's nephew and the nurse management was notified of the fall. -The facility failed to conduct a root cause analysis of the resident's fall to determine a person centered fall interventions. -A review of the resident's comprehensive care plan did not reveal the care plan was updated with person-centered fall interventions after she sustained a fall on 4/5/24. -A review of the resident's medical record did not reveal the resident was assessed by a RN after sustaining an unwitnessed fall on 4/5/24. 3. Fall incident on 4/11/24 - unwitnessed The 4/11/24 nursing progress note documented by an LPN at 11:59 p.m. revealed the resident had an unwitnessed fall. Resident 33's roommate alerted the staff that the resident was on the floor. Resident #33 was found sitting on the side of her bed. The nurse assessed and there was no apparent injury. The resident was confused and unsure how she fell . The neurological checks were continued. The resident was assisted back to bed. The on-call provider, the resident's nephew and the nurse management was notified of the fall. -The facility failed to conduct a root cause analysis of the resident's fall to determine a person centered fall interventions. -A review of the resident's comprehensive care plan did not reveal the care plan was updated with person-centered fall interventions after she sustained a fall on 4/11/24. -A review of the resident's medical record did not reveal the resident was assessed by a RN after sustaining an unwitnessed fall on 4/11/24. D. Staff interviews LPN #1 was interviewed on 4/11/24 at 9:51 a.m. LPN #1 said Resident #33 was at high risk for falls. She said the resident had several recent unwitnessed falls in her room near her bed. LPN #1 said the resident required frequent monitoring. LPN #1 said the resident needed supervision when ambulating as she forgot she could not walk without her walker and she would attempt to walk without assistive devices which put her at risk for falling. She said the resident needed to wear non-slip socks. LPN #1 said the resident had frequent falls in her room at night. She said the facility needed to explore other interventions to prevent the resident from falling. The director of nursing (DON) was interviewed on 4/11/24 at 4:25 p.m. The DON said Resident #33 often got up without assistance. She said Resident #33 sometimes forgot to use her walker. The DON said staff should offer to help the resident to lie down and place the bed in the lowest position whenever the resident went to bed. The DON said staff needed to ensure the resident's call light and personal belongings were within reach of the resident The DON said the facility needed to follow the person centered fall interventions to help prevent the resident from further falls. The DON said the nursing fall assessments were not able to be found aside from progress notes after each fall which said an LPN assessed the resident. The DON said no new interventions were implemented after each fall from 3/16/24 through 4/11/24 and the interdisciplinary team (IDT) was pending review to be completed after survey exit. The DON said she would provide education, training and audits for falls to ensure immediate interventions were put in place after a fall by nursing care staff on duty. She said she would ensure care plans were updated with person centered interventions after each fall. She said she would implement a monitoring system to ensure interventions were being followed by staff, a RN completed the post fall assessment, and ensure the IDT was completed by the next working day. The nursing home administrator (NHA) was interviewed on 4/11/24 at 4:45 p.m. The NHA said the facility would implement a fall action plan to ensure nursing care staff was provided with education and training for falls. She said the facility would implement audits to ensure immediate interventions were put in place after a fall by nursing care staff on duty. She said she would ensure care plans were updated with person centered interventions after each fall and ensure the interventions were being followed by staff. She said the facility would ensure a RN completed the post fall assessment and ensure the IDT completed a root cause analysis of the fall that included a person centered fall interventions. 43950 III. Resident #35 A. Resident status Resident #35, age greater than 65, was admitted on [DATE] and readmitted [DATE]. According to the April 2024 CPO, diagnoses included fracture of second and fourth cervical vertebra (neck fracture), rhabdomyolysis (damaged muscles), congestive heart failure (CHF) and history of falling. The 2/16/24 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of eight out of 15. She required substantial/maximal assistance with lower body dressing and partial/moderate assistance for toileting, bathing, upper body dressing, and bed mobility. She required supervision or touch assistance for transfers and walking 10 feet once standing. B. Resident interview and observation Resident #35 was interviewed on 4/8/24 at 1:50 p.m. Resident #35 said she had fallen backwards at home in January 2024 and fractured her neck. She was observed wearing a rigid cervical neck brace. She did not recall her fall at the facility in February 2024. Resident #35 was interviewed again on 4/11/24 at 10:34 a.m. Resident #35 said she did not recall her fall out of bed. She said she had just had a shower the morning of the fall. There was a sign on the wall that said Call light: press the red button when: pain, hunger, help, bathroom. Resident #35 was seated in a reclining chair in the middle of her room. -Her call light was not within reach. The call light was hooked onto her pillow that was on her bed. C. Record review Resident #35's fall care plan, initiated on 1/21/24 and revised on 2/16/24, revealed the resident was at risk for falls related to cervical fractures, CHF and chronic fatigue. Interventions included: -Be sure the resident's call light was within reach and encourage her to use it for assistance as needed. The resident needed prompt response to all requests for assistance, initiated 1/21/24, revised 1/27/24. -The resident needed a safe environment with a high-low bed in low position while she was in bed, initiated 1/21/24, revised 1/27/24. -Ensure resident was wearing appropriate footwear when ambulation or mobilizing in wheelchair, initiated 1/21/24, revised 1/27/24. -PT(physical therapy) evaluation and treatment as ordered or PRN (as needed), initiated 1/21/24. -Review information on past falls and attempt to determine the cause of falls. Record possible root causes. After review remove any potential cause if possible. Educate resident/family/caregiver as to causes, initiated 1/21/24, revised 1/27/24. -The care plan failed to document any new or revised interventions following the residents' fall on 2/11/24 to help prevent future falls. The 2/11/24 alert note revealed a CNA (certified nurse aide) alerted the nurse at 7:01 a.m. that the resident was on the floor. Resident #35 was found on the floor next to her bed. The bed was in the highest position. The resident complained of back and right hip pain. The resident was unable to verbalize what happened or how she ended up on the floor. The note documented that due to her recent fall at home and a cervical spine fracture, the nurse did not attempt to move the resident and was unable to get vital signs due to signs of trauma. EMS (emergency medical services) arrived at the facility and straightboard lifted the resident onto the gurney and took her to the hospital for evaluation. The PCP (primary care provider), resident's son and DON (director of nursing) were notified. Report was called into the hospital ED (emergency department) charge nurse. The resident's medication list, facesheet, and MOST (medical orders for scope of treatment) form were sent with the resident. The 2/12/24 nursing progress note revealed the resident was readmitted to the facility at 4:15 p.m. The resident was in a facility wheelchair with foot pedals in place and accompanied by a transportation coordinator. Resident #35 was alert and oriented to person. The current vital signs were the following: 109/64 blood pressure, 93 heart rate, 98.0 temperature, 94% oxygen saturation on 2 liters per minute of oxygen. A skin assessment was completed. The RN (registered nurse) asked the resident if it was okay to assist the resident to sit in front of the nurses station to which she nodded yes. The resident was currently in front of the nurses station wearing a neck brace and no complaint of pain or discomfort at the time. The medical doctor was notified about the resident's arrival back to the facility. The resident's medications were reviewed. Review of the hospital records revealed the following documentation: The 2/11/24 emergency room report revealed in pertinent part, the resident had an unwitnessed four foot fall out of bed. The nursing facility staff reported the resident was found on the ground and had complaints of right hip and neck pain. The resident denied hitting her head or losing consciousness. The resident did not recall the events leading up to the fall. EMS reported the resident was alert and oriented and reported to be at baseline by nursing staff. The resident was reportedly on 2 liters per minute of oxygen via nasal cannula continuously. The resident was found after the fall without her oxygen and hypoxic (deprived of adequate oxygen). The cervical collar was in place from previously known cervical vertebral fractures. The 2/11/24 hospital CT (computer tomography) scans and X-rays were negative for new fractures or dislocations. D. Facility's investigation of Resident #35's fall on 4/10/24 The fall investigation was provided by the nursing home administrator (NHA) on 4/10/24 at 12:51 p.m. It revealed the resident was found on the floor next to her bed on 2/11/24. The root cause was determined to be the resident was attempting to self-transfer. The resident had the cervical collar intact. The floor nurse notified the physician and EMR for possible trauma. The interventions included leaving the cervical collar in place, calling EMS to evaluate and send to ED for further assessment and educating the resident and floor staff to keep the resident's bed in low position with the call light within reach. The investigation documented the resident would continue with PT, occupational therapy (OT) and speech therapy (ST) as ordered. The physician and resident's son were notified of the fall. -However there were no staff interviews conducted during the investigation or new interventions added following the residents' fall to help prevent future falls. The resident's bed was not in a low position at the time of the fall. E. Staff interviews The DON was interviewed on 4/11/24 at 11:26 a.m. The DON said Resident #35's fall care plan interventions included keeping the resident's bed in the lowest position. The DON said the staff should have checked on the resident's bed frequently to ensure it was in the lowest position. The DON said the staff needed to ensure to return the bed to the lowest position after completing care. The DON said a completed fall investigation should include staff interviews, including the nurse, to help determine the root cause of the fall and appropriate new fall interventions. The DON said after a fall, immediate new interventions should be put in place to help prevent future falls and increase resident safety. The DON reviewed Resident #35's care plan and said a new intervention was not added following her fall on 2/11/24 and being sent to the hospital for evaluation. The DON said a person centered fall intervention for Resident #35 should have been updated on her care plan after she sustained a fall. The DON said it was important to implement new interventions in the care plan after a fall to prevent more falls from occurring again.The DON said she was going to complete fall education with the staff regarding the post fall process and procedure.

Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#51 and #70) of five residents reviewed for significant medication errors out of 32 sample residents. Specifically, the facility failed to: -Ensure Resident #51 received the correct medications by ensuring the correct resident was identified before administering another resident's (Resident #20) medications; -Ensure Resident #51 had documentation, monitoring and follow up for possible adverse outcomes after receiving multiple wrong medications; and, -Ensure Resident #70 was given a scheduled opioid medication according to physician orders. Findings include: I. Professional reference [NAME], A., [NAME], L. M. (September 5, 2022). Nursing Right of Medication Administration. Stat Pearls. National Library of Medicine was retrieved on 4/16/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/. It read in pertinent part, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is a standard during nursing education to receive instruction as a guide to clinical medication administration and upholding patient safety known as the five rights of medication administration. Right patient - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. This is best practiced by nurses directly asking a patient to provide his or her full name aloud, checking medical wristbands if appropriate. Depending on the unit that a patient may be in, some patients may not wear wrist bands or may have altered mentation to the point where they are unable to identify themselves correctly. In these instances, nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence. Right time - administering medications at a time that was intended by the prescriber. A guiding principle of this right is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. II. Facility policy and procedure The Medication Administration policy and procedure, reviewed 2/29/24, was provided by the director of nursing (DON) on 4/10/24 at 9:51 a.m. It read in pertinent part, Be sure you have the right resident before administering the medication by means of a photograph identification (ID), bracelet ID on resident or bracelet ID on walker/wheelchair, verification with another staff member familiar with the resident. If the resident is alert and oriented you can verify with the resident by having the resident state their full name. The Adverse Consequences and Medication Errors policy and procedure, reviewed February 2023, was received from the DON on 4/10/24 at 4/10/24 at 9:51 a.m. It read in pertinent part, In the event of a significant medication-related error or adverse consequence, take action, as necessary, to protect the resident's safety and welfare. Promptly notify the provider of any significant error or adverse consequence. Implement the provider orders and monitor the resident for 24 to72 hours or as directed, communicate the event to the oncoming shift as needed to alert staff of the need for continued monitoring. Document the following information in an incident report and in the resident's clinical record: resident's name and age, medication route, dose, date and time of administration, factual description of the error or adverse consequence, name of provider and time notified, provider's order, treatment therapy or interventions, resident's condition for 24 to72 hours or as directed. III. Resident #51 A. Resident status Resident #51, age less than 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included anoxic brain damage, heroin overdose and major depressive disorder. The 3/15/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent with eating, toileting, personal hygiene, bed mobility and transfers. B. Resident interview Resident #51 was interviewed on 4/9/24 at 9:21 a.m. Resident #51 said registered nurse (RN) #1 gave her the wrong medications a couple of weeks prior. She said RN #1 told her she had received the wrong medications from another resident and started monitoring her vital signs after it happened. She said after receiving the wrong medications she had a bad headache and urinated all day. She said she later told the assistant director of nursing (ADON) about it and the ADON wrote the information down. C. Record review Review of the other resident's (Resident #20) March 2024 medication administration record (MAR) revealed the following medications were signed off as administered (but wrongly administered to Resident #51) on 3/17/24 at 8:00 a.m. by RN #1: -Allopurinol (uric acid reducer) 100 milligrams (mg); -Amlodipine 5 mg two tablets (for hypertension); -Aspirin 81 mg (for prevention of stroke); -Atorvastatin (blood lipid reducer) 10 mg; -Ferrous Sulfate 325 mg (for anemia); -Finasteride 5 mg (for enlarged prostate); -Lasix 20 mg (diuretic); -Vitamin C 500 mg; -Carvedilol 12.5 mg (for hypertension); and, -Sodium Bicarbonate 650 mg. The 3/17/24 medication and treatment administration record (MAR/TAR) revealed documentation to assess the resident's pulse rate and notify the provider if a heart rate was less than 65 beats per minute (bpm) every two hours until 3/17/24 at 4:00 p.m. The physician's order was initiated on 3/17/24 at 9:50 a.m. It was documented as checked on 3/17/24 at 10:00 a.m., 12:00 p.m. and 2:00 p.m. -The 3/17/24 MAR/TAR failed to reveal documentation of what the pulse rate was at those times and if the provider was notified. -It failed to reveal documentation if any other vital signs, including blood pressure, were monitored. The 3/18/24 MAR/TAR revealed documentation to assess heart rate and to notify provider if a heart rate was less than 65 bpm every four hours until 3/18/24 at 8:10 p.m. It was documented as checked on 3/18/24 at 12:00 a.m., 4:00 a.m., 8:00 a.m.,12:00 p.m., 4:00 p.m. and 8:00 p.m. -The 3/18/24 MAR/TAR failed to reveal documentation of what the pulse rate was at those times and if the provider was notified. -It failed to reveal documentation if other vital signs, including blood pressure, were monitored. The 3/18/24 nurse practitioner (NP) progress notes revealed the resident had received multiple medications that were prescribed for another resident. The resident reported no adverse effects and denied cardiopulmonary, gastrointestinal or genitourinary distress. -A comprehensive review of nursing progress notes failed to reveal documentation of a medication error, notification of a provider, rationale for the additional vital sign monitoring or documentation of any additional monitoring conducted. -A comprehensive review of the March 2024 CPO failed to reveal a physician's order in the CPO on vital sign monitoring and parameters and any other monitoring required after the administration of multiple wrong medications. A 3/28/24 grievance investigation revealed Resident #51's representative had been informed by Resident #51 that she had received the wrong medications. The investigation revealed the ADON followed up with RN #1 and RN #1 denied any issues. -A review of the electronic medical record (EMAR) failed to provide evidence of a medication error. A one-to-one education was provided to RN #1 regarding policy and procedure. The 3/28/24 grievance investigation revealed documentation of an employee one-to-one education provided to RN #1 on 4/9/24 on medication administration and adverse consequences with medication error policy and procedure. The education was signed by RN #1 and the ADON on 4/9/24. -The grievance investigation failed to: -Identify the frequent vital sign monitoring on 3/17/24 and 3/18/24; -Identify the lack of documentation for the frequent vital sign monitoring; -Identify the provider documentation of a multiple medications error on 3/18/24; and, -Follow up with one-to-one education provided to RN #1 until 4/9/24, twelve days after the initial grievance was initiated and 23 days after the multiple medication errors occurred. -A comprehensive review of the April 2024 CPO failed to reveal interdisciplinary team notes (IDT) notes regarding the multiple medications error or a root cause analysis. -It failed to reveal a medication error change of condition documentation. D. Staff interviews The ADON was interviewed on 4/10/24 at 12:55 p.m. The ADON said she became aware of a potential medication error during a care conference on 3/28/24 with Resident #51, the resident's representative and the social service assistant (SSA). She said Resident #51's representative said Resident #51 had told her that she had received the wrong medications from another resident. The ADON said she assessed Resident #51 and she was at baseline. She said a grievance report was initiated and she was assigned to do the follow up. The ADON said she reviewed Resident #51's EMR and could not find evidence of a medication error. She said she interviewed RN #1 and she had no recollection of a medication error occurring. She said she was not aware of the frequent pulse check documentation in the MAR/TAR on 3/17/24 and 3/18/24. The ADON said she did a formal one-to-one education on medication administration and adverse consequences after a medication error with RN #1 on 4/9/24. She said the investigation conducted for the grievance was an informal internal investigation. She said there was a potential that a mediation error could have happened. She said if a medication error or errors occurred, a formal investigation should be done and reported to the State Agency. She said there was no review of the medication errors by the IDT risk management and no root cause analysis conducted. The DON was interviewed on 4/10/24 at 12:55 p.m. The DON said she was new to the facility and the former DON had resigned on 3/29/24. She said all nursing staff, including agency staff, should follow the five rights of medication administration. She said nurses should prepare each medication by following the orders from the EMR and matching the order to the resident's medication card. The DON said before administering any medications, nursing staff should verbally confirm with the resident, confirm with the door name tag and confirm with the picture on the MAR in the EMR. She said, if a medication error did occur, there was a policy resource in a book at the nurses station. She said the process after a medication error was to assess the individual, contact the DON, the provider and the resident's representative. She said the physician's orders for monitoring and follow up provided by the provider should be followed. The DON said a change in condition and the risk management tool located in the EMR had a step by step process on the process that needed to be followed for a medication error. She said when a multiple medication error was identified there should be a root cause analysis done to ensure further medication errors were prevented. She said, upon review of the documentation of the frequent vital sign monitoring on the TAR for 3/17/24 and 3/18/24, something had occurred and required further follow up with the nurse involved. RN #1 was interviewed on 4/10/24 at 2:17 p.m. RN #1 said she did not recall the incident and did not recall a medication error. She said if she had made a medication error she said she would have notified the provider and done additional monitoring of the resident. She said she needed to check her notes from 3/17/24. RN #1 was interviewed again on 4/10/24 at 3:15 p.m. RN #1 said she was an agency nurse who had not worked at the facility very long. She said the facility was very busy on 3/17/24. She said she could not remember how it happened, but she said she did give Resident #51 multiple wrong medications belonging to Resident #20 during the morning medication pass of 3/17/24. She said before giving a resident a medication, the resident's identity needed to be verified verbally or if the resident was not verbal, to verify with the resident's picture in the EMR. RN #1 said after she identified the multiple wrong medications she notified the nurse practitioner at the primary care provider's office. She said she reviewed the wrong medications given with the provider. She said she had been given an order to monitor blood pressure and pulse every four hours. She said she did notify the former DON. She said she did not notify Resident #51's representative but she said she had failed to put in a progress note and put in an incident report because she did not know the facility's process. The DON was interviewed again on 4/10/24 at 4:00 p.m. The DON said the follow up for the multiple medications errors included reviewing with all agency nursing staff the policies on medication administration policy and on adverse consequences and medication errors. She said she would review this with current agency staff and any new incoming staff. 48113 I. Resident #70 status Resident #70, under the age of 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included bilateral osteoarthritis resulting from hip dysplasia, depression, anxiety disorder and other chronic pain. According to the minimum data set (MDS) dated [DATE] the resident had intact cognition with a brief interview for mental status (BIMS) score of 14 out of 15. The resident did not have any rejection of care behaviors and was independent with bed mobility, transfers, locomotion, dressing, toilet use and hygiene. II. Record review The April 2024 CPO documented a physician 's order for the following pain medication: Oxycodone hydrochloride (HCl) tablet 5 mg (milligrams). Give one tablet by mouth every six hours for pain, ordered 12/12/23. The medication administration report revealed the oxycodone was to be given at 1:00 a.m., 7:00 a.m., 1:00 p.m. and 7:00 p.m. The medication administration audit report provided by the director of nursing (DON) on 4/11/24 at 9:26 a.m. for the month of March 2024 through April 2024 revealed oxycodone hydrochloride (HCl) Oral Tablet 5 MG give one tablet by mouth every six hours for pain was administered late or early (see below) on a daily basis and not according to the physician 's order. The medication administration history report documented the following for the resident 's oxycodone administrations between 3/30/24 and 4/1/24: 3/30/24: 7:00 a.m. dose The MAR entry read the medication was administered at 12:10 p.m. (four hours and 10 minutes late from the scheduled time and 10 hours and 42 minutes from the previous administered dose.) 1:00 p.m. dose The MAR entry read the medication was administered at 2:32 p.m. (32 minutes late from the scheduled time and two hours and 32 minutes from the previous administered dose, which was too early.) 7:00 p.m. dose The MAR entry read the medication was administered at 8:51 p.m. (51 minutes late from scheduled time and six hours and 19 minutes from the previous administered dose.) 3/31/24: 1:00 a.m. dose The MAR entry read the medication was administered at 12:55 a.m. (four hours and four minutes from the previous administered dose, which was too early) 7:00 a.m. dose The MAR entry read the medication was administered at 12:07 p.m. (four hours and seven minutes late from the scheduled time and 10 hours and 12 minutes from the previous administered dose.) 1:00 p.m. dose The MAR entry read the medication was administered at 5:45 p.m. (three hours and 45 minutes late from the scheduled time and six hours and 22 minutes from the previous administered dose.) 7:00 p.m. dose The MAR entry read the medication was administered at 6:57 p.m. (one hour and eight minutes from the previous administered dose, which was too early.) 4/1/24: 1:00 a.m. dose The MAR entry read the medication was administered at 2:08 a.m. (eight minutes late from the scheduled time and seven hours and 45 minutes from the previous administered dose, which was too early.) 7:00 a.m. dose The MAR entry read the medication was administered at 8:00 a.m. (five hours and 52 minutes from the previous administered dose, which was too early.) 1:00 p.m. dose The MAR entry read the medication was administered at 1:14 p.m. (six hours and 46 minutes from the previous administered dose.) 7:00 p.m. dose The MAR entry read the medication was administered at 8:05 p.m. (5 minutes late from the scheduled time and six hours and 48 minutes from the previous administered dose.) -The medication administration history report for the month of March 2024 followed the same inconsistent medication administration pattern of incorrect time administration for the resident 's oxycodone as seen above. -The facility was unable to provide incident reports for the medication errors for the time period between March 2024 through April 2024. -The facility was unable to provide progress notes to demonstrate the physician was notified of the early or late medication administrations. III. Interviews Licensed practical nurse (LPN) #1 was interviewed on 4/11/24 at 9:51 a.m. The LPN said medications that were scheduled should be administered timely which could be an hour before the scheduled time or an hour after. She said if a medication administration was administered earlier than the 1 hour before or after the scheduled time that would be a wrong time medication error. She said the electronic medical record alerted nurses only when administering medications too late but not too early and any nursing care staff that received the alert should notify the physician prior to administration. Nursing care staff should not clear the alert message and administer the medication since that would create a medication error. LPN #1 said nursing care staff should view the previous administration time prior to providing the medication to ensure six hours elapsed from the last dose in order to prevent any side effects, such as respiratory depression, if the medication was given too early. LPN #1 said she had previously administered the resident 's medications without reviewing the prior administration but she should have checked. She said she had cleared alert for administering medications too late but she did not file an incident report or notify the physician. She said moving forward she would ensure she reviewed the previous medication administration time and notified the physician if the medication was too early or if it was too late, in order to see if the physician had further orders. The director of nursing (DON) was interviewed on 4/11/24 at 4:25 p.m. The DON said a nurse should always administer medications according to the physician 's order to prevent medication errors. She said it was important to prevent errors due to the potential negative impact that pain medications might have if they were administered too late, such as the resident may exhibit pain which would negatively impact the resident 's quality of life. She said if the medications were given too early then it could lead to potential respiratory depression and even death. The DON said a nurse should review the previous administration time of a medication if scheduled to determine if the medication would be given too early and/or if the medication was going to be late. She said if the medication was outside of the physician's orders parameters, a nurse should call the physician and await new orders. She said if a nurse were to receive an alert for the medication being administered late, the nurse should stop and call the physician and await new orders and document the conversation in a nursing progress note. She said if a nurse were to ignore the message in the electronic medical record and administer the medications, the nurse should file an incident report due to administering the medication at the wrong time. The DON said she had only been at the facility for a couple of weeks and was not aware of the issue with Resident #70 's medications being administered too late or too early. She said she was not sure why the medications were being administered late or early. The DON said she needed to provide training and education to all nurses related to medication administration and incident reporting procedures for the facility to prevent wrong administration time medication errors. The nursing home administrator (NHA) was interviewed on 4/11/24 at 4:45 p.m. The NHA said a nurse should always follow the physician 's orders for medication administration and, if a nurse made an error when administering a medication, the nurse should file an incident report. The NHA said a nurse should not override the alert and administer the medications without calling the physician first. The NHA said the facility would need to provide education and training to nursing staff related to medication administration to prevent errors and to ensure if errors were identified that an incident report was filed.

Based on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for three (#6, #62 and #17) of six residents reviewed for psychotropic medications out of 25 sample residents. Specifically, the facility failed to: -Obtain appropriate risk versus benefits statements for Resident #6; -Attempt gradual dose reductions (GDR) for psychotropic medications for Resident #6; -Track and monitor behaviors accurately to justify continuation of psychotropic medications for Resident #6; -Have the residents physician document the rationale for extending the use and indicate the duration of a PRN (as needed) psychotropic medications for Resident #62 and Resident #17; -Attempt non-pharmacological interventions prior to administering PRN antipsychotics for Resident #62 and Resident #17; -Develop a resident specific care plan for psychotropic medications to include non-pharmacological interventions for Resident #62; and, -Failed to document, implement and revise Resident #17's care plan approaches to include non-pharmacological interventions. Findings include: I. Facility policy and procedure The Psychotropic Medications policy, revised 11/1/22, was provided by the director of nursing (DON) on 12/15/22 at 12:25 p.m. It read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include antipsychotics, antidepressants, anti-anxiety, and hypnotics. Psychotropic medications shall be initiated only after medical, physical, functional, psychosocial, and environmental causes have been identified and addressed. Non-pharmacological interventions that have been attempted, and the target symptoms for monitoring shall be included in the documentation. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration of 14 days. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record for the PRN order. II. Resident #6 A. Resident status Resident #6, age 79, was admitted on [DATE] and readmitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included unspecified dementia without behavioral disturbance, cerebral palsy, adjustment disorder with mixed anxiety and depressed mood, psychotic disturbance, mood disturbance, and anxiety. The 9/28/22 minimum data set (MDS) assessment revealed that the resident was unable to complete the brief interview for mental status (BIMS). According to the staff assessment for mental status, the resident had short-term and long-term memory problems, and her cognitive skills for daily decision making were severely impaired. She required two-person extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The staff assessment of resident mood revealed the resident had a score of five out of 30 which indicated mild depression. The resident did not display any potential indicators of psychosis such as hallucinations or delusions. The resident had physical and/or verbal behavior symptoms directed toward others on one to three days during the seven day look back period of the assessment. None of the behaviors put the resident or other residents at risk for injury and the behaviors did not disrupt care or the living environment. The resident had received an antipsychotic medication, an antianxiety medication, and an antidepressant medication on seven days during the seven day look back period of the assessment. B. Record review 1. Venlafaxine (Effexor) Review of Resident #6's December 2022 CPO revealed a physician's order for Venlafaxine HCL Extended Release capsule 75 milligrams (mg). Give one capsule by mouth one time a day related to adjustment disorder with mixed anxiety and depressed mood. The order date of the medication was 12/20/2020. Review of Resident #6's depression care plan, initiated 7/20/17 and revised on 8/8/21, revealed the resident had depression and became withdrawn and tearful when she was depressed. The resident received an antidepressant medication (Venlafaxine). Pertinent interventions included administering medications as ordered, observing/documenting for side effects and effectiveness of medication, encouraging individual confidence and comfort with staff by attempting to establish continuity of care as much as possible, observing/documenting/reporting as needed any signs of depression, and providing positive feedback utilizing a calm, soothing voice and gentle touch. -Review of Resident #6's Kardex (a tool utilized by CNA staff to provide appropriate care for a resident) did not include any target behaviors or non-pharmacological interventions to attempt to decrease the resident's behaviors. Behavior tracking for Venlafaxine on Resident #6's medication administration record (MAR) was reviewed from July 2022 through 12/13/22. The behavior tracking revealed the following: -July 2022: There was no behavior documentation completed on dayshift on 7/5/22, 7/9/22, and 7/29/22. One behavior was documented on dayshift on 7/20/22, but no specific behavior was documented on the MAR or in the progress notes. There were no other behaviors documented for the month. -August 2022: There was no behavior documentation completed on dayshift on 8/24/22. One behavior was documented on evening shift on 8/21/22, and dayshift on 8/26/22, but no specific target behaviors were documented in the MAR or in the progress notes. There were no other behaviors documented for the month; -September 2022: There was no behavior documentation completed on dayshift on 9/7/22, 9/9/22, 9/12/22, and 9/24/22, or on evening shift on 9/3/22. There were no behaviors documented for the entire month; -October 2022: There was no behavior documentation completed on dayshift on 10/14/22 or evening shift on 10/25/22. There were no behaviors documented for the entire month; -November 2022: There were no behaviors documented for the entire month; and, -December 2022: There was no behavior documentation completed on 12/4/22 and 12/5/22. There were no behaviors documented for 12/1/22 through 12/13/22. Review of Resident #6's electronic medical record (EMR) revealed the following physician progress notes documented in pertinent part: 8/11/22: Worsening behaviors reported by nursing. Continue Venlafaxine and BuSpar (anti-anxiety medication). Increase Zyprexa (antipsychotic medication) from every other day to every day. -The progress note did not document what the worsening behaviors were and there were no nursing progress notes in the EMR which documented the resident was having worsening behaviors. 8/30/22: Resident seen sitting comfortably in wheelchair in her room. Her expressive aphasia (loss of ability to understand or express speech) is at baseline and she does not provide any meaningful history. She is slightly agitated, though less than at last visit. Behavior has been slightly improved per staff. 9/12/22: Resident seen sitting comfortably in wheelchair. Her expressive aphasia is essentially unchanged and she does not provide any meaningful history. She is agitated as usual, no significant behavioral problems per staff. Improved on Zyprexa daily; Consider increased dose if behaviors worsen. 9/29/22: Resident seen sitting comfortably in wheelchair in her room. Her expressive aphasia is at baseline, though her emotional tender today is overwhelmingly positive and laughing, as opposed to her often combative and angry nonsensical speech. She does not appear to be in any physical pain or discomfort. No new behaviors reported by nursing. Continue Venlafaxine, and BuSpar. Slightly improved on Zyprexa daily. 10/6/22: Resident seen lying comfortably in bed in no apparent distress. She is somewhat sleepy. Does not appear to be in any distress, respiratory function seems normal. No concerns per nursing staff. No new behaviors reported by nursing. 11/10/22: Resident was seen today sitting up in her wheelchair laughing at the TV. She is alert, interactive and pleasant. Patient orientation is difficult to assess due to her cognitive status. She shows no signs of chest pain or dyspnea. She exhibits no fevers, chills or sweats. She has no cough or congestion. She shows no signs of pain or tenderness to palpation of her abdomen. Resident is able to mobilize in the hallways with a wheelchair and is well-appearing on exam. Resident has no aggressive behaviors reported by staff. Resident is pleasant today and will continue to monitor. -There were no nursing progress notes regarding behaviors documented in Resident #6's EMR, despite the physician progress notes documenting that nursing staff reported the resident's behaviors were worsening in August 2022. A risk versus benefit statement for Venlafaxine dated 8/26/21 and signed by the physician on 8/26/21 documented the current medication regimen allowed the resident to function at their highest practicable well being. -The risk versus benefit statement did not list any specific risks, specific benefits, or target behaviors for the medication, and did not include any other comments on the form. -There was no documentation to indicate that the risks versus benefits statement to justify continuing the medication was given to the resident's representative. -A Psychoactive Medication Evaluation assessment for Venlafaxine dated 9/15/22 documented Resident #6 had one to seven behavior episodes per week, despite the lack of behavior documentation in the resident's progress notes or MAR. 2. Buspirone Review of Resident #6's December 2022 CPO revealed a physician's order for Buspirone HCL 5 mg by mouth three times a day for anxiety related to anxiety disorder. The order date of the medication was 1/21/22. Review of Resident #6's anxiety care plan, initiated 4/14/2020 and revised 9/29/21, revealed the resident had an anxiety disorder and could become easily agitated when she was anxious. The resident received psychoactive medications (Buspirone and Zyprexa) for her anxiety. Pertinent interventions included administering medications as ordered, observing/documenting for side effects and effectiveness of medication, encouraging individual confidence and comfort with staff by attempting to establish continuity of care as much as possible, observing/documenting/reporting as needed any signs and symptoms of anxiety, not asking the resident lots of questions, and providing the resident with a program of activities that was meaningful and of interest. -The care plan did not document what activities helped decrease the resident's anxiety. -Review of Resident #6's Kardex did not include any target behaviors or non-pharmacological interventions to attempt to decrease the resident's behaviors. Behavior tracking for Buspirone on Resident #6's MAR was reviewed from July 2022 through 12/13/22. The behavior tracking revealed the following: -July 2022: There was no behavior documentation completed on dayshift on 7/5/22, 7/9/22, and 7/29/22. There were no behaviors documented for the entire month; -August 2022: There was no behavior documentation completed on dayshift on 8/24/22. One behavior was documented on evening shift on 8/28/22, but no specific target behaviors were documented in the MAR or in the progress notes. There were no other behaviors documented for the month; -September 2022: There was no behavior documentation completed on dayshift on 9/7/22, 9/9/22, 9/12/22, and 9/24/22, or on evening shift on 9/3/22. There were no behaviors documented for the entire month; -October 2022: There was no behavior documentation completed on dayshift on 10/14/22 or evening shift on 10/25/22. There were no behaviors documented for the entire month; -November 2022: There were no behaviors documented for the entire month; and, -December 2022: There was no behavior documentation completed on 12/4/22 and 12/5/22. There were no behaviors documented for 12/1/22 through 12/13/22. -There were no nursing progress notes regarding behaviors documented in Resident #6's EMR, despite the physician progress notes documenting that nursing staff reported the resident's behaviors were worsening in August 2022 (see physician progress notes above under Venlafaxine). -There was no risk versus benefit statement for Buspirone found in Resident #6's EMR. -There was no documentation to indicate that a risks versus benefits statement to justify continuing the medication was given to the resident's representative. -A Psychoactive Medication Evaluation assessment for Buspirone dated 9/15/22 documented Resident #6 had one to seven behavior episodes per week, despite the lack of behavior documentation in the resident's progress notes or MAR 3. Zyprexa Review of Resident #6's December 2022 CPO revealed a physician's order for Zyprexa 2.5 mg by mouth one time a day related to anxiety disorder. The order date of the medication was 8/13/22. Review of Resident #6's order history for Zyprexa revealed the resident had previously been on Zyprexa 2.5 mg one time a day every other day from 3/30/22 to 8/13/22. Review of Resident #6's behavior care plan, initiated 7/20/17 and revised 8/8/21, revealed the resident could be resistant to care and sometimes refuse to take her medication. When she was confused, the resident could be physically/verbally aggressive by hitting, pinching, biting, kicking, yelling, calling people names, and threatening to hurt someone. The resident would break or tear some of her own belongings. Pertinent interventions included administering medications as ordered, observing/documenting for side effects and effectiveness of medication, analyzing times of day, places, circumstances, triggers, and what de-escalated the resident's behaviors, giving the resident as many choices as possible about care and activities, intervening before the resident's agitation escalated, and staff to re-approach if the resident's response was aggressive. -See resident's care plan for anxiety above under Buspirone. -Review of Resident #6's Kardex did not include any target behaviors or non-pharmacological interventions to attempt to decrease the resident's behaviors. Behavior tracking for Zyprexa on Resident #6's MAR was reviewed from July 2022 through 12/13/22. The behavior tracking revealed the following: -July 2022: There was no behavior documentation completed on dayshift on 7/5/22, 7/9/22, and 7/29/22. There were no behaviors documented for the entire month; -August 2022: There was no behavior documentation completed on dayshift on 8/24/22. There were no behaviors documented for the entire month; -September 2022: There was no behavior documentation completed on dayshift on 9/7/22, 9/9/22, 9/12/22, and 9/24/22, or on evening shift on 9/3/22. One behavior was documented on dayshift on 9/1/22, but no specific target behaviors were documented in the MAR or in the progress notes. There were no other behaviors documented for the month; -October 2022: There was no behavior documentation completed on dayshift on 10/14/22 or evening shift on 10/25/22. There were no behaviors documented for the entire month; -November 2022: There were no behaviors documented for the entire month; and, -December 2022: There was no behavior documentation completed on 12/4/22 and 12/5/22. There were no behaviors documented for 12/1/22 through 12/13/22. -There were no nursing progress notes regarding behaviors documented in Resident #6's EMR, despite the physician progress notes documenting that nursing staff reported the resident's behaviors were worsening in August 2022 (see physician progress notes above under Venlafaxine). A risk versus benefit statement for Zyprexa dated 4/1/22 and signed by the physician on 4/4/22 documented the medication was an off-label use (the practice of prescribing a drug for a different purpose than what the federal drug administration approved) of the drug for refractory anxiety. -The risk versus benefit statement documented the summary of benefits was decreased anxiety and the only risk was weight gain. There were no specific target behaviors documented on the form. -There was no documentation to indicate that the risks versus benefits statement to justify continuing the medication was given to the resident's representative. -A Psychoactive Medication Evaluation assessment for Zyprexa dated 9/15/22 documented Resident #6 had one to seven behavior episodes per week, despite the lack of behavior documentation in the resident's progress notes or MAR. C. Interviews Certified nurse aide (CNA) #4 was interviewed on 12/14/22 at 12:06 p.m. CNA #4 said Resident #6 sometimes had behaviors, especially in the morning. He said the resident would yell at staff and sometimes try to hit them when staff was providing care to her. CNA #4 said if she had behaviors, staff would re-approach her after a few minutes and she would usually allow them to provide care then. Licensed practical nurse (LPN) #3 was interviewed on 12/14/22 at 1:01 p.m. LPN #3 said Resident #6 would call out, especially at night, and was occasionally resistant to care. She said the resident was sometimes agitated and had some verbal aggression. LPN #3 said Resident #6 had anxiety and was on three psychotropic medications. She said nurses were supposed to document behaviors on the MAR. She said if residents had behaviors, the nurse would document yes on the MAR and then a progress note should be documented to identify the type of behavior that occurred. LPN #3 said if no behaviors were observed, the nurse would document no on the MAR. CNA #5 was interviewed on 12/14/22 at 1:12 p.m. CNA #5 said Resident #6 would try to hit staff if she did not want to get out of bed. She said staff would leave the resident alone for a while and then the resident usually let them get her up when they tried again. The assistant director of nursing (ADON) was interviewed on 12/15/22 at 9:29 a.m. The ADON said Resident #6's MARs had some occasional missing documentation for behavior tracking each month. However, she said the majority of the resident's behavior tracking demonstrated that Resident #6 was not having behaviors which meant the resident was stable on her medications. The social services director (SSD) and the nursing home administrator (NHA) were interviewed together on 12/15/22 at 11:40 a.m. The SSD said she had only worked at the facility since the end of October 2022 and was still learning her role. The NHA said when he began working at the facility in August 2022 he identified that GDRs of psychotropic medications were not being conducted. He said the facility started a performance improvement project (PIP) to address the problem, however, he said they had not gotten very far with it because the facility did not have a SSD until the end of October 2022. He said part of the role of the SSD was to guide the GDR process, and the facility would be working toward that goal. The NHA said the facility had a monthly interdisciplinary team (IDT) meeting with the pharmacist and the medical director to discuss psychotropic medications. He said the IDT reviewed behavior tracking documentation from the MAR and progress notes for each psychotropic medication and decided as a team whether or not a GDR of the medication should be attempted. He said the recommendation for the GDR was given to the physician to approve or disapprove the GDR. The NHA said if the physician decided the medication should not be decreased, the physician would complete a risk versus benefit statement which detailed why the medication should continue at the same dose. He said the physician should have a conversation with the resident's representative about the risks versus benefits of the medications and document the conversation. The NHA said a risk versus benefit statement should include specific target behaviors being addressed for each medication. He said the physician should provide a detailed explanation about the benefits of the medication and a detailed explanation about the risks associated with prolonged use of the medication. The NHA confirmed the 8/26/21 risk versus benefit statement for Resident #6's Venlafaxine medication was not appropriately completed by the physician and did not include target behaviors or a detailed explanation of the risks versus the benefits of the medication. He confirmed the 4/1/22 risk versus benefit statement for the resident's Zyprexa medication was also not appropriately filled out by the physician, and that a diagnosis of anxiety was an inappropriate diagnosis for the antipsychotic medication. He said there was no documentation for either of the risk versus benefit statements which indicated the physician had discussed the risks versus the benefits of the medications with the resident's representative. The NHA confirmed there was not a risk versus benefit statement for the Buspirone medication in Resident #6's EMR. The NHA said the MAR and the progress notes should reflect if a resident was having behaviors. He said the MAR should have a section for nurses to document a numbered code to indicate what type of target behavior was displayed by the resident. He said the MAR should also have a section for nurses to document a numbered code to indicate what non-pharmacological interventions were attempted to decrease the behavior. He said nurses should also document a detailed progress note about the behavior and interventions in the electronic medical record (EMR). The NHA confirmed Resident #6's MAR did not provide sections for the nurses to document the type of behavior the resident displayed or the non-pharmacological interventions staff attempted to decrease the behaviors. He said there was no way to know what behavior the resident had or if interventions were attempted to decrease the behavior when it occurred because there was not a place for the nurses to document that information on the MAR if the nurse marked yes for a behavior. The NHA said specific target behaviors and non-pharmacological interventions for each medication should be documented on the resident's care plan. He said the behaviors and interventions should also be included on the CNA Kardex so that CNAs knew the best way to work with a resident's behaviors. The NHA confirmed that specific target behaviors and non-pharmacological interventions for each of Resident #6's psychotropic medications were not documented on the care plan or the CNA Kardex. The NHA said Resident #6's behavior tracking monitoring indicated the resident was not displaying very many behaviors. He said based on the documentation that the resident was not having behaviors, there was nothing to justify the continuation of Resident #6's psychotropic medications at the doses she was currently receiving. The NHA said that all three of the resident's psychotropic medications should have had GDRs attempted. D. Facility follow up On 12/15/22 at 1:12 p.m., the NHA provided a copy of the PIP the facility initiated to address the problem of the facility's failure to conduct GDRs for psychotropic medications. The PIP was initiated on 10/1/22. The plan identified that psychotropic meetings were not occurring consistently, GDRs were not being tracked or documented appropriately, and behavior tracking was not accurate compared to known behaviors. The plan listed two action items: to recruit for a SSD and to set up a meeting with the new director of nursing and the medical director to discuss the expectation for staff and providers regarding GDRs and behavior tracking. The meeting occurred on 10/6/22. -The plan did not have any further action items listed to address GDRs and behavior tracking. -Nothing further had been done on the PIP since 10/6/22. III. Resident #62 A. Resident status Resident #62, age above 65, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), the diagnoses included hydrocephalus (fluid build up in the brain), Alzheimer's disease, Parkinson's disease, and cerebrovascular disease (stroke). The 10/3/22 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of seven out of 15. He had no behaviors and did not reject care. He required extensive assistance with ADLs (activities of daily living). B. Record review The December 2022 CPO documented Resident #62 was ordered, in pertinent part: -Haloperidol Lactate Concentrate 2 mg (milligrams)/ml (milliliters). Give 0.5 ml by mouth every four hours PRN for agitation/hallucinations. This was ordered on 8/29/22 with no end date. -Lorazepam give 0.5 mg by mouth every four hours PRN for restlessness/agitation/anxiety. This was ordered 8/7/22 with no stop date. The PRN Lorazepam was administered on 11/24/22. The November 2022 CPO did not list or document any non-pharmacological interventions prior to the administration of the PRN anti-anxiety medication. Progress notes There were not any non-pharmacological interventions documented in the resident's progress notes or any behavior documentation to indicate why the PRN Lorazepam was administered. Care Plan The resident's comprehensive care plan was reviewed on 12/13/22. -There were no care plans initiated for the use of psychotropic medications, mood, behaviors, or non-pharmacological interventions. A care plan for Haloperidol and Lorazepam was initiated on 12/14/22, during the survey. -However, the care plans did not include non-pharmacological interventions. IV. Resident #17 A. Resident status Resident #17, age above 65, was admitted on [DATE]. According to the December 2022 CPO, the diagnoses included anxiety disorder, shortness of breath , insomnia, altered mental status, chronic obstructive pulmonary disease (COPD), and metabolic encephalopathy (problem in the brain). The 11/6/22 MDS assessment revealed, the resident had moderate cognitive impairment with a BIMS of 12 out of 15. He had no behaviors and did not reject care. He required extensive assistance with transfers and toilet use. He had shortness of breath or trouble breathing when lying flat. B. Record review The December 2022 CPO documented Resident #17 was ordered, in pertinent part: -Lorazepam Intensol Concentrate 2 mg/ml. Give 0.5ml by mouth every four hours PRN for SOB (shortness of breath) or pain. This was ordered on 11/21/22 with no stop date. The PRN Lorazepam had never been administered. The anti-anxiety care plan, initiated 11/21/22. It documented the resident used the anti-anxiety medication for SOB or pain. It did not include non-pharmacological interventions. V. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 12/15/22 at 9:17 a.m. She said non-pharmacological interventions should be attempted before giving a PRN medication and it should be documented in the progress notes. She said all PRN psychotropic medications should be reassessed every 14 days. Registered nurse (RN) #1 was interviewed on 12/15/22 at 9:34 a.m. She said non-pharmacological interventions should be tried before giving a PRN medication and it should be documented in the progress notes. She said all PRN psychotropic medications should be reassessed every 14 days. She said psychotropic medications should have a care plan and non-pharmacological interventions should be included in the care plan. The director of nursing (DON) was interviewed on 12/15/22 at 10:12 a.m. She said all PRN psychotropic medications should have a care plan in place that targets behavior, interventions, monitoring, and non-medication interventions. She said going forward she would place an order for non-medication interventions and make sure care plans were in place. She said all PRN psychotropic medications should be reassessed every 14 days for continued use. The nursing home administrator (NHA) was interviewed on 12/15/22 at 11:38 a.m. He said PRN psychotropic medications should be reassessed every 14 days, even if ordered by hospice. He said care plans should be in place for the psychotropic medications including non-pharmacological interventions. He said non-pharmacological interventions should be attempted before giving a PRN medication. He said there should be documentation on behaviors and non-pharmacological attempts on the medication administration record (MAR). 42840

Based on observations and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (#120) of six residents out of 25 sample residents. Specifically, the facility failed to ensure a licensed practical nurse (LPN) administered medications for Resident #120 without touching the medications with her bare hands. Findings include: I. Facility policy and procedure The Medication Administration policy, last revised on 11/1/22, was provided by the assistant director of nursing (ADON) on 12/14/22 at 11:41 a.m. It read in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Wash hands prior to administering medication per facility protocol. Remove medication from source, taking care not to touch medication with bare hands. II. Resident status Resident #120, age 68, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included sepsis, osteomyelitis of vertebra, pneumonia, heart failure, essential hypertension, and disorder of kidney and ureter. III. Observation of medication administration On 12/14/22 at 9:34 a.m., LPN #4, an agency nurse, was observed preparing medications to administer to Resident #120. LPN #4 sanitized her hands with alcohol-based hand rub (ABHR) before beginning to prepare the medications. She then proceeded to knock on the resident's door with her bare hand. LPN #4 did not sanitize her hands again after knocking on the resident's door. She did not sanitize her hands prior to touching the medication with her bare fingers. LPN #4 removed a bottle of multivitamins from a drawer on the medication cart. She opened the bottle and poured one tablet directly from the bottle onto the top of the medication cart. LPN #4 picked up the multivitamin with her bare fingers and placed the medication into a plastic medication cup before replacing the lid on the bottle and returning the bottle to the drawer. LPN #4 proceeded to remove a bottle of ferrous sulfate (iron) tablets from a drawer on the medication cart. She opened the bottle and poured three tablets directly from the bottle onto the top of the medication cart. LPN #4 picked up one tablet with her bare fingers and placed the medication into the medication cup. She then picked up the remaining two tablets from the top of the medication cart and put them back into the medication bottle before replacing the lid on the bottle and returning the bottle to the drawer. LPN #4 did not sanitize her hands prior to touching the medication with her bare fingers. LPN #4 proceeded to remove all of the prepackaged bubble pack medication cards containing Resident #120's morning medications from another drawer on the medication cart. The nine medications included, Allopurinol 100 milligrams (mg), pantoprazole sodium (Protonix) 40 mg, Tamsulosin HCL (Flomax) 0.4 mg, Torsemide 20 mg, Xarelto 20 mg, Gabapentin 300 mg, Potassium Chloride extended release 10 milliequivalents (MEQ), Methocarbamol 500 mg, and Bentyl 20 mg. LPN #4 picked up the Allopurinol medication card and proceeded to pop one tablet out of the bubble pack card directly into the palm of her left hand. Using the fingers of her right hand, LPN #4 picked up the medication from the palm of her left hand and placed the medication into the medication cup. She did not sanitize her hands prior to touching the medication with her bare fingers. LPN #4 proceeded to dispense the eight remaining prepackaged medications in the same manner that she dispensed the Allopurinol. For each medication, LPN #4 popped the medication out of the bubble pack directly into the palm of her left hand before picking up each medication with the bare fingers of her right hand and placing the medications into the medication cup. She did not sanitize her hands prior to touching any of the medications with her bare fingers. IV. Interviews LPN #4 was interviewed on 12/14/22 at 9:41 a.m., prior to administering the medications to Resident #120. LPN #4 said she was an agency nurse and was working at the facility for the first time. She said she sanitized her hands with ABHR prior to preparing the medications for Resident #120. She said after she sanitized her hands, she knocked on the resident's door to see if he was ready for his medications. LPN #4 said she should have sanitized her hands again before preparing the medications. LPN #4 said she should not have poured medications directly onto the medication cart or touched the medications with her bare fingers. She said touching medications with bare fingers would be considered an infection control issue as the medications could be contaminated due to improper hygiene practices. LPN #4 said she would need to dispose of the contaminated medications and prepare the medications again before administering the medications to Resident #120. The ADON was interviewed on 12/14/22 at 9:55 a.m. The ADON said LPN #4 should have sanitized her hands again after she knocked on Resident #120's door, prior to preparing medications for the resident. She said medications should never be placed directly on the medication cart or handled with bare hands. The ADON said handling the medications with bare hands contaminated the medications and was an infection control concern. She said she would discuss the concern with LPN #4. V. Facility follow up On 12/14/22 at 10:16 a.m., the ADON provided a copy of an education she had conducted with LPN #4 regarding following infection control processes during medication administration. The education sheet had been signed by the ADON and LPN #4.

Based on observations, record review and interviews, the facility failed to ensure medication error rates were not 5% or greater. Out of 25 opportunities for medication errors, 10 errors were observed, resulting in an error rate of 40%. These errors affected one (#120) of six residents out of 25 sample residents. Specifically, the facility failed to ensure medications for Resident #120 were not administered late. Findings include: I. Professional reference According to Perry, Potter and Ostendorf, (copyright 2017), Fundamentals of Nursing (ninth edition), page 614, Safe drug administration involves adherence to prescribed doses and dosage schedules. Follow the medication administration policies of your agency about the timing of medications to ensure that you administer medications at the right time. II. Facility policy and procedure The Medication Administration policy, last revised on 11/1/22, was provided by the assistant director of nursing (ADON) on 12/14/22 at 11:41 a.m. It read in pertinent part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician, and in accordance with professional standards of practice. Compare medication source (bubble pack, vial, etc.) with medication administration record (MAR) to verify resident name, medication name, form, dose, route, and time. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. III. Resident status Resident #120, age 68, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included sepsis, osteomyelitis of vertebra, pneumonia, heart failure, essential hypertension, and disorder of kidney and ureter. IV. Observation and record review On 12/14/22 at 9:34 a.m., licensed practical nurse (LPN) #4 was observed during a medication pass as she was prepping medications to administer to Resident #120. LPN #4's laptop screen showed the administration boxes for each medication were red. At 9:34 a.m., LPN #4 began preparing Resident #120's medications, which included the following medications: -Allopurinol 100 milligrams (mg) by mouth one time a day; -Ferrous Sulfate 325 mg by mouth one time a day; -Pantoprazole Sodium (Protonix) delayed release tablet 40 mg by mouth one time a day; -Tamsulosin HCL (Flomax) 0.4 mg by mouth one time a day; -Torsemide 20 mg by mouth one time a day; -Xarelto 20 mg by mouth one time a day; -Gabapentin 300 mg by mouth two times a day; -Potassium Chloride Extended Release 10 milliequivalents (MEQ). Give two tablets by mouth two times a day; -Methocarbamol 500 mg by mouth three times a day; and, -Bentyl 20 mg. Give two capsules by mouth four times a day. At 9:50 a.m., LPN #4 finished preparing the medications and administered the medications to Resident #120. Review of Resident #120's December 2022 computerized physician orders (CPO) revealed all of the above medications were scheduled to be given at 8:00 a.m. V. Interviews LPN #4 was interviewed on 12/14/22 at 9:41 a.m. LPN #4 said when the medication tiles were red, it meant the medications were late. She said she was an agency nurse and unfamiliar with the residents which had slowed her down and she was behind on her medication pass. LPN #4 said Resident #120's medications were scheduled to be administered at 8:00 a.m. She said she had a one hour window of administration time on either side of a scheduled medication administration time. LPN #4 said Resident #120's medications could be given between 7:00 a.m. and 9:00 a.m. She said the resident's medications should have been administered no later than 9:00 a.m. The ADON was interviewed on 12/14/22 at 9:55 a.m. The ADON said medications that were scheduled to be administered at 8:00 a.m. had an administration window of 7:00 a.m. to 9:00 a.m. She said the medications that were given at 9:50 a.m. to Resident #120 were considered late for administration. The ADON said medications that were administered late were considered medication errors. The director of nursing (DON) was interviewed on 12/14/22 at 11:26 a.m. The DON said medications administered outside the administration window were considered medication errors because they were given late. She said the best practice for the administration of Protonix was to give the medication on an empty stomach at least half an hour before breakfast. She said the best practice for the administration of Flomax and Xarelto was to give the medications at the same time every day. The DON said she had no best practice concerns regarding the other medications as long as Resident #120 received them, however, she said the medications were still considered late administrations.

Based on record review and interviews, the facility failed to notify the resident representative when there was a significant change in a resident's condition for one (#4) of four residents reviewed out of seven sample residents. Specifically, the facility failed to notify the resident's representative when Resident #4 experienced a choking episode with apnea (temporary cessation of breathing). Findings include: Record review confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/20-4/21/2022, resulting in the deficiency being cited as past noncompliance with a correction date of 4/6/2022. I. Facility policy and procedures The Notification of Changes policy, dated 10/1/21, was provided by the nursing home administrator (NHA) on 4/21/22 at 10:05 a.m. It read in pertinent part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. The facility must inform the resident, consult with the resident's physician and /or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: accidents, significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status. This may include:life-threatening conditions, clinical complications, or circumstances that require a need to alter treatment, a transfer or discharge of the resident from the facility, a change of room or roommate assignment, and a change in resident rights. II. Resident status Resident #4, age 70, was admitted on [DATE] and discharged to the hospital on 4/2/22. The resident did not return to the facility. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/25/22 minimum data set (MDS) assessment revealed that the resident was cognitively intact with a brief interview for mental status (BIMS) of 13 out of 15. He required two-person extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. He required two-person total assistance for transfers. III. Record review Review of Resident #4's electronic medical record (EMR) revealed the following progress notes: 4/1/22 at 11:23 a.m: Resident with apneic period of 30 to 45 seconds following medication administration at 10:00 a.m. Registered nurse (RN) performed assisted cough (forceful push on the abdomen given at the same time as a cough is attempted) three to four times, and the resident began to breathe again. Shortly after, the resident began coughing with pills and clear sputum expelled. Vital signs following the incident were within normal limits. Nurse practitioner (NP) was notified and she evaluated the resident. -The progress note did not document that the resident's representative was notified of the choking incident. 4/2/22 at 9:27 a.m: Family in to visit Resident #4 on this date. 4/2/22 at 6:55 p.m: Resident sent to hospital emergency room for evaluation and treatment. Resident's representative was notified. A nurse practitioner's note dated 4/1/22 documented the following, in pertinent part: The resident is seen at the request of nursing status post [MEDICAL RECORD OR PHYSICIAN ORDER] . He currently denies pain. He does not recall that he had a choking episode this morning. He denies any fevers, chills or malaise and denies any cardiopulmonary, gastrointestinal or [CONDITION(S)] distress. Per nursing, the resident began choking on pills this morning. Nursing administered abdominal thrusts and were able to clear his airway. Resident continued to 'cough up pills' while in the shower. Brief episode of apnea noted by staff but resident recovered on his own without intervention. Resident was luckily sitting up allowing nursing to do abdominal thrusts. Resident cleared his airway. However, while in the shower, the resident was 'coughing up pills' . Lungs are currently clear but given continued cough and high risk of aspiration, chest x-ray scheduled for Saturday and can be changed to stat (urgent) for any signs of toxicity or [CONDITION(S)]. -The nurse practitioner's note did not document that the resident's representative was notified of the examination or the plan to obtain a chest x-ray. It also indicated the resident recovered on his own without interventions, however, the resident needed nursing interventions as mentioned in the paragraph above and in the progress note dated 4/1/22. A Situation/Background/Appearance/Request (SBAR) Communication Form assessment dated [DATE] documented the change of condition being assessed was the family's concern related to Resident #4's cognition, weight loss and tremors. The assessment further documented that the recent choking episode made the condition worse, and the physician gave new orders to transfer the resident to the hospital. -Review of Resident #4's EMR did not reveal a SBAR Communication Form assessment for the choking episode on 4/1/22. On 4/20/22 at 2:49 p.m., the NHA provided a concern form dated 4/6/22. The concern form documented the following in pertinent part: Received phone call from Resident #4's representative who was upset and frustrated that she was not notified of the resident's decline or change of condition. The concern form further documented the action plan was to provide education to the nursing staff regarding what a change of condition looked like, and when to notify the physician and the resident's representative of a change of condition. On 4/20/22 at 4:42 p.m., the NHA provided a copy of a written education sheet dated 4/6/22 which addressed change of condition. It read in pertinent part, When to document and complete change of condition in residents, use of the SBAR. Report changes in level of consciousness, speech clarity, changes in bladder or bowel patterns, changes in required assistance with activities of daily living (ADLs), dressing or feeding, changes in appetite, swallowing difficulties, change in medications, labs, x-rays, etc. Any of the above require being assessed and documented to include actions taken, and notifications to the representative and the physician. IV. Interviews Licensed practical nurse (LPN) #1 was interviewed on 4/21/22 at 2:03 p.m. LPN #1 said a change of condition would be anything outside of a resident's baseline condition. She said a change of condition could include a change in vital signs, cognition, skin issues, falls, or anything else that was not a normal condition for a resident. LPN #1 said anytime a resident was observed to have a change of condition, nurses filled out the SBAR Communication Form assessment and notified the physician for further orders. She said the resident's representative should also be notified of the resident's change of condition. LPN #1 said she would consider a choking episode a change of condition and a SBAR Communication Form should be filled out and the resident's representative notified. The care management director (CDM), director of nursing (DON), and the regional director of clinical reimbursements (RDCR) were interviewed together on 4/21/22 at 2:34 p.m. The CDM said a change of condition was considered to be anything that was a change from the resident's baseline. She said a change of condition could include a change in the resident's mentation, decreased appetite, sustained abnormal vital signs that don't respond to treatment, and skin issues. She said when a change of condition occurred, the nurse should assess the resident, initiate the SBAR Communication Form assessment, and notify the physician. The CMD said a resident's representative should be notified for a change of condition. The CMD said she would consider an actual choking episode a change of condition. She said the progress note for Resident #4's incident documented an assisted cough was performed and not the [MEDICATION(S)] maneuver, and so she was not sure if the resident actually choked. However, she said an SBAR Communication Form assessment should have been filled out and the resident's representative notified of the incident and the order for the chest x-ray. The CMD confirmed that there was no SBAR Communication Form assessment in the resident's EMR and no documentation indicating that Resident #4's representative had been notified of the incident.

Based on record review, and interviews the facility failed to provide treatment and care in accordance with professional standards of practice for two (#1 and #2) out of four sample residents. Specifically, the facility failed to obtain and administer medications correctly to Resident #1 and #2 according to physician orders. Findings include: I. Facility policy and procedure The Medication Administration policy, revised June 2008, was received from the director of nursing (DON) on 2/10/21 at 12:06 p.m. The policy documented in pertinent part, Medications are administered in accordance with written orders of the attending physician .Begin new medication orders timely. Begin routine orders on the same day ordered, unless the next dose would be normally given the next day. Administer medications within 60 minutes of the scheduled time. II. Resident #1 A. Resident status Resident #1, age 61 ,was admitted on [DATE]. According to the October 2020, computerized physician orders [REDACTED]. The 10/3/2020 minimum data set (MDS) assessment documented the resident's memory was Ok and she was able to make decisions regarding tasks of daily living. A brief interview for mental status (BIMS) assessment was not completed. Resident #1 required extensive one person assistance with bed mobility, transfers, dressing, and toileting. She required supervision for personal hygiene, and had fallen one time since admission 9/30/2020. Resident #1 was on a scheduled pain medication regime and PRN (as needed) pain medications. B. Record review The medication administration records (MAR) and physician orders [REDACTED]. Medications were not administered according to physician's orders [REDACTED]. -Pramipexole [MEDICATION NAME] tablet 0.125 mg (milligram), give one tablet by mouth at bedtime for restless leg syndrome. On 9/30/2020 at 8:00 p.m., the medication was not documented as given. Instead it was coded with an 8. An 8was listed on the MAR legend, as other, see progress notes. The nursing progress notes, dated 9/30/2020 at 9:33 p.m. documented the medication was not given because it was not available, pharmacy is sending. There was no documentation in the progress notes that the nurse notified the physician the medication was not available, or requested further orders. -[MEDICATION NAME] Tablet 20 mg, give one tablet by mouth two times a day for attention. On 9/30/2020 at 8:00 p.m., the medication was not documented as given. Instead, it was coded with an 8. The nursing progress notes, dated 9/30/2020 at 9:31 p.m., documented the medication was not given because it was not available, pharmacy is sending. There was no documentation in the progress notes that the nurse notified the physician the medication was not available, or requested further orders. -Aspirin tablet 325 mg, give 325 mg by mouth one time a day for heart health. On 10/2/2020 at 8:00 a.m., the medication was not documented as given. Instead, it was coded with an 8. There was no progress note. -[MEDICATION NAME] Tablet 20 mg, give one tablet by mouth two times a day for attention. On 10/1/2020 at 8:00 a.m. and 12:00 p.m., the medication was not documented as given. Instead, both were coded with an 8. On 10/1/2020 at 9:07 a.m. the nursing progress notes documented the medication was not given because it was not available. On 10/1/2020 at 1:20 p.m., the nursing progress notes documented the medication was not available, script pending. There was no documentation in the progress notes, that the physician was notified or that the resident had already missed three doses of the medication due to it being not available. -[MEDICATION NAME] HCL tablet 5 mg, give one tablet by mouth every six hours as needed for pain of 5 to 7 out of 10. [MEDICATION NAME] HCL tablet 5 mg, give two tablets by mouth every six hours as needed for pain of 8to 10 out of 10. On 10/2/2020 at 3:21 a.m., Resident #1 rated her pain a 9 out of ten. The October 2021 MAR documented she was only given one tablet of [MEDICATION NAME], which was half the ordered dose if her pain was 8 to 10. On 10/3/2020 at 8:45 a.m., Resident #1 rated her pain 5 out of 10. The October 2021 MAR documented she was given two tablets of [MEDICATION NAME], twice the ordered dose for pain of 5 out of 10. On 10/3/2020 at 4:27 p.m., Resident #1 rated her pain a 1 out of 10 and she was given two tablets of [MEDICATION NAME], twice the ordered dose. C. Resident family interview Resident #1's son was interviewed by phone on 2/11/21 at 2:01 p.m. He said he was not aware the facility had administered the wrong amount of narcotic pain medication, Oxycpodone to his mother. He was not aware of the other missed medications. He said he did have concerns about medications for his mother. Resident #1's son said the first night she was there, the nurse asked him to bring in one [MEDICATION NAME] (sleep medication) because the facility did not have the medication. He said the next night they called him to bring in another dose of the [MEDICATION NAME], because they still did not have the medications. III. Resident #2 A. Resident Status Resident #2, age 75, was admitted on [DATE]. According to the January 2021, computerized physician orders [REDACTED]. The 1/20/21 minimum data set (MDS) assessment, documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #2 required extensive two person assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. B. Record review The medication administration records (MAR) and physician orders [REDACTED]. Medications were not administered according to physician's orders [REDACTED]. Apixaban Tablet, give 2.5 mg by mouth two times a day for [MEDICAL CONDITION] (blood clot) prevention. The order was dated 1/27/21 at 7:36 p.m. The MAR documented the medication was given on 1/27/21 at 8:00 p.m. The following morning on 1/28/21 at 8:00 a.m., the medication was documented as not given, with a code of an 8. The nurses progress notes dated 1/28/21 at 8:49 a.m. documented the medication was not given because of delivery pending. There was no documentation that the facility notified the physician that the resident had not received the anticoagulant medication to prevent blood clots. III. Staff interviews Registered nurse (RN) #1 was interviewed on 2/10/21 at 9:31 a.m. She said meditations were automatically ordered from the pharmacy when the orders were entered in the computer resident medical record system by the physician or nurse. She said medications for new admissions came from the pharmacy or the facility had a supply of some medications. She said the facility's main pharmacy vendor had a contract with a local pharmacy to get the facility medications quickly in an urgent situation. She said when a medication was not available, she would notify the pharmacy and document in the resident progress notes it was not available. She said she would notify the DON. RN #1 then said, maybe we could notify the physician and see if they wanted a substitute or something. The DON was interviewed on 2/10/21 at 9:59 a.m. She said medications for new admissions come in the afternoon or night pharmacy delivery to the facility. She said if the nurse did not have a medication when it was scheduled to be given, they should call the physician to get the order changed or an order to hold the mediaciot until it is available. She said the nurse should then write a progress note and obtain an order from the physician to hold the medication until it arrived or get an order for [REDACTED].#1. She said she would review the medication omissions and errors for both residents. The DON was interviewed again on 2/10/21 at 10:35 a.m. The DON said the [MEDICATION NAME] and Pramipexole were not given as ordered for Resident #1 and the physician should have been notified. She confirmed Resident #1 was admitted around 1:00 p.m. on 9/30/2020, and the facility did not have her medications by that night. She said she reviewed the narcotic count sheets for the [MEDICATION NAME], for Resident #1. She confirmed the medication was not given according to physicians orders as described above. Additionally, she said the blood thinning medication, Abixapan, was not given to Resident #2 on 1/28/21 because it had not arrived from the pharmacy. The DON said the nurses should have notified the physician and gotten orders or at least documented a note that the physician was notified of the missed medications.

Based on record review and interviews, the facility failed to ensure two (#1 and #2) out of four sample residents, received adequate supervision and assistance devices to prevent accidents. Specifically, the facility failed to recognize and accurately assess the risk of falls, and implement care planned interventions to prevent falls for Resident #1 and Resident #2. Findings include: I. Facility policy and procedure The Fall Management policy, dated 11/2007, was received from the director of nursing (DON) on 2/10/21 at 12:06 p.m. The policy documented in pertinent part, newly admitted residents, a proactive approach will be taken for newly admitted residents with regard to fall risk .upon admission the admitting nurse will complete the fall risk, the nursing initial plan of care, address risk factors related to the resident in the plan of care and implement appropriate interventions as identified. The Kardex will be updated to reflect the residents risk status and individualized fall risk interventions. The Resident and residents representative are provided education on fall risk interventions in place to reduce the potential for falls. II. Resident #1 A. Resident status Resident #1, age 61, was admitted on [DATE]. According to the October 2020, computerized physician orders [REDACTED]. The 10/3/2020 minimum data set (MDS) assessment documented the residents memory was Ok and she was able to make decisions regarding tasks of daily living. A brief interview for mental status (BIMS) assessment was not completed. Resident #1 required extensive one person assistance with bed mobility, transfers, dressing, and toileting. She required supervision for personal hygiene, and had fallen prior to admission and one time since admission 9/30/2020. Resident #1 was on a scheduled pain medication regime and PRN (as needed) pain medications. B.Record review The discharge summary from the hospital dated 9/21/2020 was reviewed. The summary documented, Resident #1 had chronic wound dehiscence from a spinal surgery. She had a drain and a [DEVICE]. Resident #1 tripped over her walker and [DEVICE] at home and fractured her left ankle. A skilled nursing facility was recommended for rehabilitation, with plans to return home after. Resident #1's admission fall risk assessment, dated 9/30/2020 was reviewed. The fall risk assessment documented the resident was not at risk for falls despite the resident admitting for a fall at home with fracture. The fall risk assessment was not completed accurately. The assessment documented a score of 10 indicated a fall risk. Resident #1 had a score of three, which was not accurate. The assessment did not account points for her current fracture, or points for the correct number of medications she was on. The score should have been 12, indicating she was a fall risk. Resident #1's care plan was reviewed. There was no comprehensive care plan for fall prevention. She had a baseline care plan started on 10/2/2020. The care plan was incomplete. The section regarding falls and fall risk was blank. There was no Kardex (tool used by nursing staff to deliver care) regarding fall risk or preventative measures. An SBAR (situation, background, assessment and recommendation) note, dated 10/3/2020 at 7:19 a.m. was reviewed. The note documented Resident #1 had a witnessed fall, with no injury. The SBAR documented the resident had medication changes in the last week. The resident said the medications were different than what she was on at home. The SBAR documented the problem may be due to poor balance, left lower extremity fracture, and weakness. There were no recommendations related to the fall and preventing further falls. The physician was notified at 6:00 p.m., over 10 hours later and the resident's son was notified at 5:00 p.m., over nine hours later. The interdisciplinary (IDT) post fall note initiated on 10/3/2020 at 7:40 a.m., and locked on 10/6/2020 at 9:25 a.m., was reviewed. The IDT note documented the resident was uncooperative with safe transfer instructions from staff during transfer to toilet, not wearing proper footwear, wanted minimal assistance, stand pivot of left lower extremity, lost balance and dropped to her knees. The fall occurred in the bathroom during an assisted transfer. Predisposing diseases and conditions that may have contributed to fall were, left lower extremity fracture, unsteady gait, history of falls, change in medications, and admission in the last 30 days. Footwear and assistive devices at the time of all were documented as none. Environmental factors listed in the bathroom documented crowded. Medications that may have contributed were listed as psychoactive and narcotics. The resident was on cardiovascular medications, [MEDICATION NAME] and Losartan. The IDT did not check the box indicating the resident was on these medications. The IDT summary documented a summary fall, would not allow staff to assist adequately, declined lift. Recommendations were to educate on the use of the lift and appropriateness for transfers due to level of assist needed. However, there was no documentation that the resident needed a lift to transfer. It was unclear as to who would be educated, the staff who did not use a lift, or the resident. There were no further recommendations. The October 2020, computerized physician orders [REDACTED]. There were no PT or OT assessments in the chart from the date of admission 9/30/2020 through discharge 10/3/2020. The therapy assessments were requested from the rehabilitation director on 2/10/21 at 1:25 p.m. On 2/10/21 at 2:13 p.m. a one half page document was received via email, from the nursing home administrator (NHA), which documented the case was open. There was no information regarding any type of assessment of the resident. The email further documented the Evaluation was opened on 10/1/2020, was not completed due to the patient being out of the facility on 10/1/2020 and 10/2/2020. C. Resident family interview Resident #1's son was interviewed by phone on 2/11/21 at 2:01 p.m. He said on 10/3/2020 the facility did not notify him of the fall until after he spoke to his mother on the phone on 10/3/2020 around 4:00 p.m. He said Resident #1 was in a lot of pain. He said Resident #1 told him the staff were transferring her in the bathroom that morning, they were holding the back of her pants and she did not have a gait belt on and she fell on her knees. He said his mother told him the bathroom was small and the nurse and the wheelchair could not fit in the bathroom so the nurse stood outside the bathroom door, and held the resident by the pants from behind the wheelchair. The resident's son said the facility nurse told him two stories. First, the nurse said they were holding the resident by the pants and she went down to the floor. Then the facility nurse told him they were not holding her and she fell to her knees. Resident #1's son said he took his mother home that night against medical advice. He was concerned she was there for therapy and had fallen at home and the facility did not have a plan to keep her from falling. Additionally, Resident #1's son said when his mother had x-rays on 10/5/2020, there was a new spinal fracture above the old fracture, that was not on the x-ray from 10/1/2020. He contributed this to her fall 10/3/2020. The imaging was not available at the time of the survey. D. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 2/10/21 at 9:16 a.m. He said he did not recall Resident #1. He said the nursing staff looked at the Kardex to determine how to transfer a resident and whether they were at risk for falls. There was no Kardex, baseline or comprehensive care plan for Resident #1 who was at risk of falling. CNA #2 was interviewed on 2/10/21 at 12:57 a.m. She said she did not know where to find the information on how a resident transfers, she said I have only been here four days. Registered nurse (RN) #1 was interviewed on 2/10/21 at 9:31 a.m. She said she got a report from the hospital on how a resident transfers when they were admitted to the facility. She said how a resident transferred should be documented on the care plan and the CNA Kardex. The DON was interviewed on 2/10/21 at 11:32 a.m. She said the nurse would have received a verbal report from the hospital on how the resident transferred and then therapy would assess her and notify the staff of their recommendations. The DON said a resident's transfer status should have been on the CNA Kardex and care plan. She confirmed there was no Kardex for Resident #1. Additionally, there was no fall care plan for Resident #1, and the baseline care plan was blank in the fall section. She said the CNA's would have known how to transfer Resident #1 by verbal report to each other. The DON said Resident #1 should have been transferred with a gait belt and a wheelchair with stand by assistance from staff. However, the 10/3/2020 MDS documented the resident needed extensive assistance from staff. The DON said she did not use a lift. The DON said the IDT note dated 10/3/2020 was referring to using a lift after the fall. She further said Resident #1 was in a hurry to get to the bathroom and the CNA did not offer or assist her with footwear, but should have. III. Resident #2 A. Resident Status Resident #2, age 75, was admitted on [DATE]. According to the January 2021, computerized physician orders [REDACTED]. The 1/20/21 minimum data set (MDS) assessment, documented the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. Resident #2 required extensive two person assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. She was occasionally incontinentof bladder and frequently incontinet of bowel. She had not fallen. B. Record review The fall risk assessment dated [DATE] documented Resident #1 was not a fall risk. The resident scored an eight. The assessment did not include all of the medications the resident was on and should have been a score of 12. The fall risk assessment documented a score above 10 was at risk for falling. The Kardex as of 2/10/21 was reviewed. The Kardex did not document how to transfer the resident or any fall precautions. It documented Mobility, Resident #2 in non weight bearing on the right lower extremity. There was no further documentation. The baseline care plan dated 1/16/21 was reviewed. The baseline care plan documented Resident #2 was not at risk for falling. It further documented she required extensive two person assistance with transfers. The comprehensive care plan initiated 1/16/21 was reviewed. The care plan did not include a plan to prevent falls. The PT assessment dated [DATE] documented, precautions, right lower extremity, non weight bearing, fall risk. The assessment documented Resident #2 required maximal assistance with transfers, helper does more than half the effort, helper lifts or holds the trunk or limbs and provides more than half the effort. C. Resident interview Resident #2 was interviewed on 2/10/21 at 12:55 p.m. She said sometimes the nursing staff transferred her with two people and sometimes they used one person. She said it depends on who was on duty that day. She said she feared falling. D. Staff interviews CNA #2 was interviewed on 2/10/21 at 12:57 p.m. She was assigned to provide care to residents where Resident #2's resided. She said she did not know how Resident #2 transferred and she did not know where to locate information on how to transfer her. CNA #3 was interviewed on 2/10/21 at 12:58 p.m. She said Resident #2 transferred with extensive one person assistance. She said the Kardex documented how a resident transferred. She pulled up the resident's Kardex on the computer. The Kardex had been updated since the morning when it was first reviewed and did not contain how the resident transferred or fall risk prevention measures. The Kardex documented Resident #2 was a two person extensive assistance. However, the staff had reported she transferred with one person assistance. Licensed practical nurse (LPN) #1 said she was assigned to care for Resident #2. She said Resident #2 transferred with one person assistance. The DON was interviewed on 2/10/21 at 11:32 a.m She said a fall risk assessment was done on the resident's admission and then quarterly. She said the risk assessment generated the fall care plan. She reviewed Resident #2's fall risk assessment and baseline care plan. She said the fall risk assessment was not accurate and did not include all the medications the resident was on. The DON said the baseline care plan was not accurate. She said Resident #2 was at risk of falling and there was no current fall prevention plan in place. She reviewed Resident #2's Kardex and said it did not include information on how to transfer the resident or fall risks. The DON said there should have been a fall prevention care plan, she said I do not know what happened.

Based on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as COVID-19 in two of four neighborhoods. Specifically, the facility: -Failed to ensure hand hygiene was completed between glove changes while staff cleaned resident's rooms; -Failed to ensure staff doffed contaminated gloves before exiting resident rooms; and, -Failed to ensure residents covered their noses and mouths when staff were in their rooms. Findings include: I. Professional reference According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last updated 1/31/2020, retrieved on 8/10/2020 from https://www.cdc.gov/handhygiene/providers/index.html, included the following recommendations: Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. II. Facility policy and procedure The Infection Control policy and procedure, last updated 7/15/2020, was provided by the nursing home administrator (NHA) on 8/4/2020 via email. It read in pertinent part, Remove and discard gloves when leaving the resident room or care area, and immediately perform hand hygiene by washing hands with soap and water or using an alcohol-based hand sanitizer that contains 60 to 90 percent alcohol for at least 20 seconds. Resident use of face masks, when possible, when COVID-19 symptoms are present or not, residents should cover their nose and mouth whenever staff is in their room. Residents can use tissue to do this or they can use cloth non-medical masks when those are available. III. Observations A. Failure to perform hand hygiene while cleaning resident rooms. On 8/4/2020 at 10:40 a.m., housekeeper (HK) #1 was observed standing in front of room [ROOM NUMBER] located on unit three hall, with her cleaning cart, preparing to clean the resident's room. She had a pair of gloves on. She picked up a disinfectant from her cleaning cart and proceeded into the resident's room which was shared by two residents. She sprayed the disinfectant in the sink and in the toilet. After she was done spraying the disinfectant, she removed the trash from the room and proceeded to her cleaning cart. She removed her gloves and did not perform hand hygiene. She donned a clean pair of gloves. She took a wet rag from the cleaning cart from a bucket of solution and proceeded into the resident's room. She started cleaning the right side which was one resident's side of the room. She wiped down the bedside table, the dresser and the call light button. She proceeded to her cleaning cart and removed her gloves without performing hand hygiene. She donned a clean pair of gloves. She took another wet rag from the bucket of solution on her cleaning cart. She proceeded in the resident's room and started to clean the left side which was the other resident's side of the room. She wiped down the bedside table, the dresser, call light button, drawer handles and light switches. She proceeded to her cleaning cart and removed her gloves without performing hand hygiene. She donned a clean pair of gloves. She took another wet rag from the bucket of solution on her cleaning cart and proceeded to the resident's bathroom. She wiped down the sink and the toilet. She exited the bathroom and proceeded to her cleaning cart. She removed her gloves and did not perform hand hygiene. She donned clean pair gloves. She took the mop from her cleaning cart and proceeded to the resident's room. She mopped the floor. She removed her gloves and washed her hands. At 10:54 a.m., she proceeded to room [ROOM NUMBER] with her cleaning cart. She donned a pair of gloves. She picked the disinfectant from her cleaning cart and proceeded in the resident's room which was shared by two residents. She sprayed the disinfectant in the sink and in the toilet. She proceeded to her cleaning cart and placed the disinfectant on the cart. She proceeded in the room and removed the trash from the room. She placed the trash in the trash bag on her cleaning cart. She removed her gloves and did not perform hand hygiene. She donned clean gloves. She removed a wet rag from a bucket of solution on her cleaning cart and proceeded to the resident's room. She started cleaning the right side which was one resident's side of the room. She wiped down the bedside table, the dresser, drawers and call light button. After she had finished cleaning one side of the resident's room, she wiped down the door handles and light switches. She proceeded to her cleaning cart. She removed her gloves and did not perform hand hygiene. She donned a clean pair of gloves. She took a wet rag from the bucket of solution on her cleaning cart and proceeded to the other side (left side) of the room which was the other resident's side. She wiped down the bed side table, the dresser and the call light button. She proceeded to the bathroom and wiped down the sink and the toilet. She exited the bathroom and proceeded to her cleaning cart. She removed her gloves without performing hand hygiene and donned a clean pair of gloves. She took the mop from her cleaning cart and proceeded in the room. She mopped the floor. She proceeded to her cleaning cart. She removed her gloves and washed her hands. B. Failed to ensure staff removed contaminated gloves before exiting the resident care area. On 8/5/2020 at 9:58 a.m., certified nurse aide (CNA) #1 was observed in room [ROOM NUMBER]. She was measuring the resident's vital signs. After she was done measuring the resident's vital signs, she exited the room with her contaminated gloves on and proceeded down the hall to another resident's room, potentially spreading infection. She removed her contaminated gloves into another resident's room and she washed her hands. C. Failed to ensure residents covered their noses and mouths when staff were in their rooms. On 8/5/2020 at 10:05 a.m., CNA #1 entered Resident #1's room. The resident was sitting up in her wheelchair. There was no covering over the resident's nose and mouth. CNA #1 told the resident she was in her room to measure her vital signs. She did not offer the resident a face covering while she was in her room. -At 10:20 a.m., CNA#1 entered Resident #2's room. The resident was lying in her bed. She had a face mask on. The mask did not cover the resident's nose. The mask was below the resident's nose. CNA #1 bent over to the resident and told her she was in her room to measure her vital signs. She did not encourage or offer the resident to cover her nose while she was in her room. -At 10:25 a.m., CNA #1 proceeded to Resident #3 in the same room. The resident was lying in bed. There was no covering over the resident's nose and mouth. She bent over the resident and told her she was in her room to measure her vital signs. She did not offer the resident a face covering while she was in her room to prevent possible development and transmission of COVID-19. IV. Staff interviews HK #1 was interviewed on 8/4/2020 at 11:10 a.m. She said she received training on COVID-19 that was provided by her supervisor. She said the training included the steps on cleaning resident's rooms, dwell times for chemicals and handwashing. She said she was trained to wash her hands with soap and water after she was done cleaning the room. She said she was not aware that she should perform hand hygiene every time she removed her gloves. She said moving forward, she would perform hand hygiene every time she removed her gloves. CNA #1 was interviewed on 8/5/2020 at 10:17 a.m. She said she received training on COVID-19 that was provided by the director of nursing (DON). She said the training included signs and symptoms of COVID-19, handwashing, social distancing, face covering for residents when out of their rooms, disinfecting shared medical equipment before and after use and appropriately donned and doffed personal protective equipment (PPE) correctly. She said she was aware that contaminated gloves should be removed before exiting the resident's room after providing care. She said when she measured the resident's vital signs, she forgot to remove her gloves before exiting the resident's room. She said she did not receive training about offering the resident to cover their noses and mouths while staff was in their rooms. She said moving forward she would ensure to offer residents to cover their noses and mouths when in their rooms. The housekeeping supervisor (HKS) was interviewed on 8/5/2020 at 10:00 a.m. She said she was responsible for the housekeeping and laundry department. She said she provided education to her staff on COVID-19 and the training was ongoing as new updates became available. She said the training included the signs and symptoms of COVID-19, handwashing and the process of cleaning the resident's room. She said HK#1 was trained to perform hand hygiene every time she removed her gloves while cleaning the resident's room to prevent the development and the transmission of COVID-19. She said HK #1 should have performed hand hygiene every time she removed her gloves and before putting on clean gloves and would provide additional training to HK #1. The DON, who was also the infection control preventionist, was interviewed on 8/5/2020 at 11:07 a.m. She said she had been in her position since June 2020. She said there were no current cases of COVID-19 at the facility. She said she provided training to all staff on COVID-19. She said the training included handwashing and PPE since June 2020. She said the staff received training on COVID-19 prior to her being in her position. She said the training included signs and symptoms of COVID-19, how COVID-19 was transmitted, facemask, social distancing, hand washing and PPE. She said all staff were trained to wash their hands with soap and water or to use the alcohol-based hand sanitizer every time gloves were removed to prevent the development and transmission of infection. She said HK #1 should have performed hand hygiene every time she removed her gloves before donning on clean gloves. She said CNA #1 received training on the appropriate way to doff PPE. She said she should have removed her contaminated gloves before exiting the resident's room to prevent the spread of possible infection. She said she had not trained staff to offer residents to cover their noses and mouth when staff was in their rooms providing care. She said she would immediately educate all staff to offer residents face covering when they are in their rooms providing care. V. Facility follow-up On 8/5/2020 at 12:05 p.m., the DON provided an in-service training form dated 8/5/2020, that she provided to CNA #1. It documented: gloves should be removed before exiting the patient room, hand hygiene performed before leaving the room. When providing patient care, encourage patients to wear face covering to prevent possible transmission. On 8/6/2020 at 1:53 p.m., the NHA provided an in-service training form dated 8/4/2020 via email. It documented: infection control, hand washing, donning and doffing It revealed the training was provided to laundry and housekeeping staff.

Based on observations, record review, and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection such as coronavirus (COVID-19) in three of four halls observed for infection control practices. Specifically, the facility failed to: -Ensure proper personal protective equipment (PPE) isolation techniques were followed for COVID-19 positive Residents (#1, #3, #6, #7 and #8), isolation rooms 202, 206, and readmission isolation room [ROOM NUMBER]; -Ensure proper hand hygiene was performed during donning and doffing of PPE; and, -Ensure thorough screenings for COVID-19 symptoms were documented for Residents (#1, #3, #6, #7 and #8). Findings include: I. Isolation/PPE usage and hand hygiene A. The Centers for Disease Control (CDC) references According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 3/20/2020, retrieved online from https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_HCP_COVID19_PPE.pdf: -PPE must be donned correctly before entering the patient area. - PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas. PPE should not be adjusted. - Face masks should be extended under the chin. - Both your mouth and nose should be protected . The CDC (2020) Coronavirus Infection Control Recommendations, retrieved from :https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed in part, Healthcare professionals (HCP) should continue to adhere to Standard and Transmission-Based Precautions, including use of eye protection and/or an N95 or equivalent or higher-level respirator based on anticipated exposures and suspected or confirmed diagnoses. Universal use of a facemask for source control is recommended for HCP. Accessed on 7/13/2020. The CDC (2020) Hand Hygiene, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/hand-hygiene.html, revealed in part, Hand hygiene is an important part of the U.S. response to the international emergence of COVID-19. [MEDICATION NAME] hand hygiene, which includes the use of alcohol-based hand rub (ABHR) or handwashing, is a simple yet effective way to prevent the spread of pathogens and infections in healthcare settings. CDC recommendations reflect this important role. The exact contribution of hand hygiene to the reduction of direct and indirect spread of coronaviruses between people is currently unknown. However, hand washing mechanically removes pathogens, and laboratory data demonstrate that ABHR formulations in the range of alcohol concentrations recommended by CDC, inactivate [DIAGNOSES REDACTED]-CoV-2. ABHR effectively reduces the number of pathogens that may be present on the hands of healthcare providers after brief interactions with patients or the care environment. The CDC recommends using ABHR with greater than 60% [MEDICATION NAME] or 70% [MEDICATION NAME] in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less irritating to hands and are effective in the absence of a sink. Accessed on 7/13/2020. B. Facility policy Review of the Infection Prevention Strategies and Guidance for COVID-19 policy, updated 7/1/2020, provided by the nursing home administrator (NHA) on 7/9/2020 at 1:00 p.m., read in pertinent part: The center should ensure that all staff are using appropriate PPE when they are interacting with patients and residents to the extent PPE is available. Staff should perform hand hygiene, which includes washing hands with soap and water or using an alcohol-based hand sanitizer that contains 60 to 95% alcohol for at least 20 seconds, as appropriate. Conservation strategies should be followed by the center, as necessary, to provide care to the residents and protection for staff. -PPE Surgical face masks should be worn by suspected or confirmed COVID-19 residents when leaving their room for any reason and suspected or confirmed COVID-19 residents when direct care is being provided. N95 respirators should be worn by direct care staff caring for suspected or confirmed COVID-19 residents. Full PPE is recommended in dedicated areas where residents with suspected or confirmed COVID-19 are located. Reusable eye protection (e.g., goggles, face shields) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. To reuse eye protection, perform hand hygiene, apply a clean pair of gloves. Carefully wipe the inside of the face shield or goggles, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with environmental protection agency (EPA)-registered hospital disinfectant solution and ensure dwell time is met. Fully dry (place eye protection on a clean paper towel on a clean surface). Remove gloves and perform hand hygiene. Remove and discard gloves when leaving the resident room or care area, and immediately perform hand hygiene by washing hands with soap and water or using an alcohol-based hand sanitizer that contains 60 to 95% alcohol for at least 20 seconds. Keep in mind that glove use doesn't eliminate the need for hand hygiene. -Hand sanitizing Apply alcohol-based hand rub to the palm of one hand and then rub your hands together, covering all surfaces of your hands. Continue rubbing your hands together until all of the product has dried (usually about 30 seconds). C. Manufacturer's instructions Review of the manufacturer's instructions for the Medline Micro-Kill bleach wipe and the bleach-free and alcohol-free disinfectant cleaner wipe, provided by the NHA on 7/9/2020 at 1:03 p.m., read in pertinent part: Our comprehensive disinfectant wipes help reduce risks of cross-contamination and transmission of microorganisms listed on label when used on hard, non-porous surfaces and equipment. -The overall kill time was three minutes for the bleach wipe and 10 minutes for the bleach-free/alcohol-free wipe, the surface must remain wet with the product to achieve disinfection. -The bleach-free/alcohol-free wipe kills 13 microorganisms (coronavirus was not among those listed). The wipe was not to be used on medical equipment. -Individual protection measures include wearing protective gloves. D. Staff education Review of the staff education regarding use of PPE (donning and doffing) provided by the NHA on 7/9/2020 at 1:03 p.m. revealed a date of 3/26/2020 and the education regarding extended use-proper procedures of PPE use was dated 4/7/2020. -The NHA did not provide documentation of any education completed after 4/7/2020. II. Observations and staff interviews On 7/8/2020 at 1:45 p.m. in the common area on the south wing, there was an exit door to the enclosed smoking area. The COVID-19 positive residents were on hall 3 on the south wing. An unknown resident was seen reentering the facility from the smoking area. She used ABHR from a dispenser on the wall next to the door. She swiped her hands together then wiped them on her shorts, readjusted her mask, and proceeded to exit the wing. She passed hall 3 on her way back to the north wing. -At 2:00 p.m. the resident care specialist/certified nurse aide (RCS/CNA) exited COVID-19 positive room [ROOM NUMBER] on south hall 3. She was wearing a surgical mask and her personal glasses. She walked to hall 4 and entered readmission isolation room [ROOM NUMBER]. She did not change her mask or don an N95 mask, goggles or a face shield. After exiting the room she hooked her personal glasses, by the earpiece, into the front of her shirt. The RCS/CNA was interviewed at 2:10 p.m. She said she was supposed to wear an N95 mask and goggles when entering COVID-19 positive resident rooms. She said those items were stored in a paper bag in a room on south hall 2 and staff retrieved them when they needed to enter the positive isolation or quarantine rooms. She acknowledged she did not wear the appropriate PPE when she entered the positive room or the quarantine room. She said her goggles were laying on the counter at the nurse's station and her N95 mask was in the room on hall 2. -At 2:25 p.m. registered nurse (RN) #1 entered isolation room [ROOM NUMBER] wearing full PPE. She exited the room at 2:27 p.m. wearing goggles and an N95 mask. She walked down the hall, removed both items and placed them on top of her medication cart (med cart) with the outside of the mask laying on the cart. She did not clean the goggles or place the mask in its storage bag. -At 2:30 p.m. the NHA provided documentation of one-to-one education she completed with the RCS /CNA that read, The appropriate PPE must be worn before entering an isolation room. The following PPE is required: -N95 -Face shield/goggles -Gown -Gloves -At 2:37 p.m. the medical doctor (MD) was seen standing at the nurse's station leaning on the raised edge of the wooden counter. He was wearing an N95 mask and gloves. He was documenting on paper in front of him. He had his personal stethoscope draped over his shoulder and a pulse oximeter, provided by RN #1, in his gloved hand. -At 2:42 p.m. the MD approached COVID-19 positive room [ROOM NUMBER] wearing the same gloves. There was no eye protection available for him. RN #1 retrieved her goggles from on top of her med cart, did not clean them, and handed them to the MD. He did not clean the goggles and placed them over his glasses. After applying the goggles, he donned a gown. He then removed the gloves and donned a clean pair. He did not perform hand hygiene prior to donning the clean gloves. He then reached under the gown, retrieved his stethoscope, placed it on top of the gown on his shoulder, and tied the gown. He did not sanitize the stethoscope or the pulse oximeter prior to entering the resident room. -RN #1was interviewed at 2:45 p.m. She acknowledged she did not sanitize her goggles after she exited isolation room [ROOM NUMBER] and placed them on top of the med cart. She said she gave the goggles and a pulse oximeter to the MD to use in the COVID-19 positive room. She said she did not clean them prior to giving them to the MD. She asked, Should I have cleaned them before I gave them to him? -At 2:48 p.m. the MD exited room [ROOM NUMBER] wearing gloves and the goggles. He went to the nurse's station, placed his stethoscope and the pulse oximeter on the ledge next to his paperwork and pen. RN #1 provided the MD with an alcohol-free/bleach-free wipe to clean the pulse oximeter. He used the same wipe to clean his stethoscope. He then placed the soiled wipe on the ledge where it then fell to the floor. He did not pick it up. Still wearing the gloves, he picked up his ink pen and documented on the paper in front of him, touching the paper, his pen, and the ledge. He then wrote something on the palm of his gloved right hand. At this time RN #1 cleaned the goggles with the alcohol-free/bleach-free wipe, with her bare hands and handed them back to the MD. -At 2:57 p.m. the MD walked to south hall 2 to enter isolation room [ROOM NUMBER]. Wearing the same gloves, he approached the isolation cart outside the room. He placed his stethoscope on top of the cart, donned a gown, then placed his stethoscope over his shoulder and entered the room. He did not perform hand hygiene or change gloves. -At 3:04 p.m. the MD exited room [ROOM NUMBER]. He was wearing gloves and goggles. He obtained a disinfecting wipe and cleaned his stethoscope then walked back to close the door to room [ROOM NUMBER]. He removed the goggles and cleaned them with the same wipe he cleaned the stethoscope with and placed both items on top of the isolation cart. He then removed the gloves and used the same wipe to clean his bare forearms. He did not perform hand hygiene and went to the nurse's station with the gloves in his hand and placed them on the ledge next to his pen and paper. He made documentation on his paperwork and returned to hall 2 to enter another isolation room. -At 3:08 p.m. the MD donned gloves and a gown without performing hand hygiene and entered isolation room [ROOM NUMBER]. -At 3:17 p.m. the MD exited room [ROOM NUMBER] wearing an N95 mask and gloves. He approached the nurse's station and applied ABHR to his gloved hands and spread the ABHR onto his bare forearms. He then exited the south wing into the main part of the building wearing the N95 mask and the gloves, carrying his pen and paper. On 7/9/2020 at 9:33 a.m. the nurse practitioner (NP) was seen exiting COVID-19 positive room [ROOM NUMBER]. She was wearing a face shield but no mask. She did not perform hand hygiene, went to the nurse's station and placed her stethoscope on the counter, then obtained a disinfecting wipe to clean it and placed it around her neck. She cleaned the face shield and waved it in the air. -At 9:48 p.m. COVID-19 positive Resident #8 was seen opening the door to her room with her mask below her nose. Staff passed her and did not acknowledge her. She proceeded into the hall. A staff member approached her wearing a surgical mask, donned a gown and gloves. She did not don goggles, a face shield, or an N95 mask, and assisted Resident #8 into her room while leaning forward near the resident's face to speak to her. -At 9:54 a.m. RN #2 was seen entering COVID-19 positive room [ROOM NUMBER]. She was carrying packages of paper towel to place at the sink area in the room. She was wearing a surgical mask and did not don any other PPE. She exited that room, did not perform hand hygiene, opened the door to COVID-19 positive room [ROOM NUMBER], entered, and used the ABHR near that sink, then exited that room. -At 9:57 a.m., while in COVID-19 positive room [ROOM NUMBER], the activity director (AD) told the resident she did not have to wear a mask. -From 10:30 a.m. to 10:41 a.m. Resident #8 had exited her room grabbing onto the isolation cart in the hall. She was not wearing a mask. RN #2 approached the resident wearing only a surgical mask. She did not don PPE. She grabbed the handles of the resident's wheelchair with her bare hands. RN #2 bent forward near the resident's face to encourage her to return to her room. The resident refused. The scheduler approached the resident as well. She applied a surgical mask to the resident's face with her bare hands and the resident immediately pulled it down. She did not don PPE and was only wearing a surgical mask. The resident continued to refuse to return to her room. The scheduler brought Resident #8 a cup of water which the resident then sat on top of the isolation cart. The scheduler then walked away from RN #2 and Resident #8 and entered a supply room to obtain items for another staff member in an isolation room on hall 4. She did not perform hand hygiene. RN #2 then knelt next to Resident #8's wheelchair, to speak to her face to face. Resident #8 did not have her mask on. After Resident #8 agreed to return to her room, the scheduler walked away to hall 2 to obtain her N95 mask and face shield. She did not perform hand hygiene prior to donning PPE. -At 10:41 a.m. RN #2 entered COVID-19 positive room [ROOM NUMBER], wearing a surgical mask, to wash her hands. She did not don any other PPE. She then exited that room and walked to isolation room [ROOM NUMBER]. She entered the room to talk to the resident wearing the same surgical mask and did not don any other PPE. -At 10:43 a.m. RN #2 exited isolation room [ROOM NUMBER], walked to hall 1 and entered non isolation room [ROOM NUMBER]. She was wearing the same surgical mask. -At 11:26 a.m. the AD was observed to use ABHR, rubbing her hands together for eight seconds then waving her hands in the air as she exited the south hall. -At 11:26 a.m. the scheduler donned PPE to enter COVID-19 positive room [ROOM NUMBER], she did not perform hand hygiene prior to donning gloves. She entered the room with a sit-to-stand lift that had been in the hall with a sling draped over it. At 11:34 a.m. she exited the room with the lift and the sling draped over the machine. She placed the lift in the hallway outside room [ROOM NUMBER] and did not clean it. -At 11:30 a.m. RN #2 entered COVID-19 positive room [ROOM NUMBER] wearing only a surgical mask. She spoke to the resident, exited the room and returned with an N95 mask and a face shield. She donned PPE but did not perform hand hygiene prior to donning gloves. -At 11:37 a.m. RN #2 exited isolation room [ROOM NUMBER]. She used a disinfecting wipe to clean the face shield then waved it vigorously in the air and placed it on top of the isolation cart outside room [ROOM NUMBER]. -At 11:38 a.m. the RCS/CNA and the scheduler entered isolation room [ROOM NUMBER] with the sit-to-stand lift and the sling that had been parked in the hall outside room [ROOM NUMBER]. They did not clean the machine prior to using it or when they exited the room with it at 11:50 a.m. The sling was no longer on the machine. -At 11:41 a.m. Resident #8 was seen exiting her room in her wheelchair with no mask on. She was grabbing a hold of the hand rails on each side of her room door to help propel herself out into the hall. RN #2 was wearing a surgical mask and donned a gown and gloves to assist the resident back into her room. She did not perform hand hygiene prior to donning the gloves. She did not don an N95 mask, goggles or a face shield. She bent down into the resident's face multiple times to speak to her. -At 11:44 a.m. RN #2 exited room [ROOM NUMBER] wearing the gown and gloves. She removed those items in the hallway and reentered the resident room to dispose of them and washed her hands at the sink in the room. She did not sanitize the handrails in the hallway that Resident #8 was holding onto when she exited her room. -At 11:52 a.m. RN #2 was seen again on hall 3 outside a COVID-19 positive isolation room waving her face shield in the air after she cleaned it. -At 12:15 p.m. Resident #8 was observed in her room seated in her wheelchair in front of the hand washing sink, eating with her lunch plate on the counter next to the sink. Staff did not acknowledge her or redirect her. -At 12:17 p.m. RN #2 exited COVID-19 positive isolation room [ROOM NUMBER]. She cleaned her face shield and waved it in the air stating, It takes forever for it to dry. -At 12:48 p.m. RN #2 entered COVID-19 positive isolation room [ROOM NUMBER] to deliver medication and when she exited at 12:52 p.m. she again cleaned her face shield and waved it in the air to dry. There were multiple observations on 7/8/2020 and 7/9/2020 of residents from the north wing entering the south wing through closed double doors, having to walk around the nurse's station, past COVID-19 positive and isolation rooms on halls 3 and 4, to exit into the smoking area. When they reentered the building they took the same path back to the north wing. RN #1 said it was the only way for the residents from the north wing to get to the smoking area. The NHA and the director of clinical services (DCS) were interviewed on 7/9/2020 at 1:10 p.m. They said gloves were a one time use item and were to be disposed of after each use. Staff were not to wear gloves in the hallways at any time. They said this applied to any physician or NP that treated residents in the facility. They said the isolation rooms did not have designated vital sign equipment so the MD used his personal stethoscope when he examined residents. They said they needed to provide direct one-to-one education to the MD and physician staff. They said staff were to follow the correct procedures for donning and doffing PPE. They said it was not appropriate for the north wing residents to have to enter the south wing and pass by the COVID-19 positive hall to go out to smoke. They said effective immediately they would set up a smoking area off the north wing for those residents. III. COVID-19 status in the building A. Staff interviews The nursing home administrator (NHA) and director of clinical services (DCS) were interviewed on 7/8/2020 at 3:43 p.m. They said they had two positive COVID-19 residents and four positive COVID-19 staff. They said they started weekly testing for residents and staff on 6/22/2020. They said everyone was asymptomatic. They said they were classified as an outbreak on 6/24/2020 or 6/25/2020. The NHA was interviewed again on 7/9/2020 at 9:30 a.m. She said there were three more positive COVID-19 residents resulting in a total of five positive COVID-19 residents in the building. She said three other residents were waiting for their second negative test. She said they did not have an infection prevention staff member at this time. She said the director of nursing (DON) was new in the position and was currently on vacation. The NHA and the DCS were interviewed again on 7/9/2020 at 1:10 p.m. They said they had a total of 20 resident deaths associated with COVID-19. B. Professional reference Review of the COVID-19 checklist for long term care facilities (LTCFs) for preparation and rapid response, https://drive.google.com/file/d/1ej-1kbX20euOGJHkcgO5zJb1TTD1Lf87/view, dated 5/13/2020, revealed Prevention: Active monitoring of all residents should occur once daily to include temperature, heart rate, blood pressure, respiratory rate, pulse oximetry .Rapid response: Increase active monitoring of all residents to two times daily to include temperature, heart rate, blood pressure, respiratory rate, pulse oximetry, changes in mental status and any symptoms (cough, shortness of breath, difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory (smell) and taste disorder) .Ill residents should be monitored at least three times a day. Accessed 7/13/2020. The CDC ((2020) Preparing for COVID-19 in Nursing Homes, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, revealed in part, Actively monitor all residents upon admission and at least daily for fever .and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement Transmission-Based Precautions as described below .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. Accessed 7/14/2020. IV. Resident screening A. Resident #1 1. Resident status Resident #1, age 68, was admitted on [DATE]. According to the July 2020 computerized physician orders [REDACTED]. 2. Record review Review of the June 2020 and July 2020 medication administration record (MAR) and treatment administration record (TAR) revealed the resident was being monitored for blood pressure, respirations and O2 (oxygen) saturation two to three times a day. Temperature and pulse was monitored once a day. COVID-19 monitoring increased to every four hours on 7/8/2020 for temperature, pulse, respirations and O2 saturations. Review of the progress notes revealed the following: On 7/8/2020 at 16:55 (4:55 p.m.): Resident notified of COVID+ results. She was informed that she will be moved to a different room for isolation. The vitals summary documentation for June 2020 and July 2020 revealed: -Pulse and temperatures were monitored once a day for the month of June. -Pulse was monitored once a day on 7/1, 7/2, 7/3, 7/5, 7/6 and 7/7/2020 and temperatures were monitored once a day on 7/1, 7/2, 7/3, 7/5, 7/6 and 7/7/2020. Resident screening/monitoring should have been completed twice a day once illness was identified in the facility. B. Resident #3 1. Resident status Resident #3, age 76, was admitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. 2. Record review Review of the June 2020 and July 2020 MAR and TAR revealed the resident was being monitored for pulse, respirations and O2 saturations every four hours from 6/4 to 6/7/2020; for blood pressure, pulse, respirations and O2 saturations once a day from 6/7 to 6/8/2020; for blood pressure, temperatures, pulse, O2 saturations and respirations every four hours from 6/8 to 6/18/2020; or temperatures, pulse and O2 saturations every shift (twice a day) from 6/18 to 7/2/2020; for temperatures, pulse and O2 saturations every shift from 5/7 to 7/2/2020; and for temperature, pulse, respirations and O2 saturations every four hours from 7/2/2020 until current. Blood pressure was monitored once. Review of the facilities COVID-19 tracking; Resident #3 tested positive on 6/29/2020. The vitals summary documentation for June 2020 and July 2020 revealed: -O2 saturations were monitored twice a day on 6/30, 7/1/2020. -O2 saturation monitoring was blank on 6/7/2020. -Respiration monitoring was blank on 6/1, 6/2, 6/3, 6/7 and 6/19 through 7/1/2020. -Pulse rate monitoring was blank on 6/7/2020, -Pulse rate was monitored twice a day on 6/30 and 7/1/2020. -Temperature monitoring was blank on 6/5, 6/6 and 6/7/2020. -Temperatures were monitored twice a day on 6/30 and 7/1/2020. -Blood pressure monitoring was blank on 6/1 through 6/7 and 6/18 through 7/2/2020. -Blood pressure was monitored once a day on 7/3, 7/4, 7/5, 7/6, 7/7 and 7/8/2020. Resident screening/monitoring should have been completed once a day before illness was identified in the facility; twice a day once illness was identified in the facility; and increased to three times a day for ill residents (6/29/2020). C. Resident #6 1. Resident status Resident #6, age 90, was admitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. 2. Record review Review of the June 2020 and July 2020 MAR and TAR revealed the residents were being monitored for blood pressure, temperatures, pulse, O2 saturation and respirations every shift from 5/7 through 7/8/2020. The residents were being monitored for temperatures, pulse, respirations and O2 saturations every four hours from 7/8/2020 to current. Blood pressure was monitored once. Review of the progress notes revealed: On 7/8/2020 at 16:54 (4:54 p.m.): Resident notified of COVID+ results. She was informed that she will be moved to a different room for isolation. The vitals summary documentation for June 2020 and July 2020 revealed: -Respiration monitoring was blank from 6/1 through 7/7/2020. -Blood pressure was monitored once a day on 6/24 through 7/8/2020. Resident screening/monitoring should have been completed once a day before illness was identified in the facility and twice a day once illness was identified in the facility. D. Resident #7 1. Resident status Resident #7, age 69, was admitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. 2. Record review Review of the June 2020 and July 2020 MAR and TAR revealed the resident was being monitored for temperature, pulse and O2 saturations every shift from 5/7 through 7/8/2020. The residents were being monitored for temperature, pulse, respirations and O2 saturations every four hours from 7/8/2020 to current. Review of the progress notes revealed: On 7/8/2020 at 16:53 (4:53 p.m.): Resident notified of COVID+ results. He was informed that he will be moved to a different room for isolation. The vitals summary documentation for June 2020 and July 2020 revealed: -O2 saturations were monitored once a day on 6/29/2020, -Respiration monitoring was blank from 6/1 through 6/5/2020, 6/7 through 6/11/2020, 6/13 through 6/22/2020 and 6/25 through 7/6/2020. -Pulse was monitored once a day on 6/29/2020. -Temperature was monitored once a day on 6/29/2020. -Blood pressure monitoring was blank on 6/1 through 6/5/2020, 6/7 through 6/11/2020, 6/13 through 6/22/2020, 6/25 through 7/1/2020 and 7/3 through 7/6/2020. -Blood pressure was monitored once a day on 6/24, 7/2, 7/7 and 7/8/2020. Resident screening/monitoring should have been completed once a day before illness was identified in the facility and twice a day once illness was identified in the facility. E. Resident #8 1. Resident status Resident #8, age 95, was admitted on [DATE]. According to the July 2020 CPO, [DIAGNOSES REDACTED]. 2. Record review Review of the June 2020 and July 2020 MAR and TAR revealed the resident was being monitored for blood pressure, temperatures, pulse, respirations and O2 saturations twice a day from 5/23 through 7/2/2020. The resident was monitored for temperature, pulse and respirations every four hours from 7/2/2020 through current. Review of the facilities COVID-19 tracking; Resident #8 tested positive on 6/29/2020. The vitals summary documentation for June 2020 and July 2020 revealed: -Respiration monitoring was blank on 6/11 through 7/1/2020. -Pulse was monitored once a day on 7/1/2020. -Blood pressure was monitored once a day on 7/2, 7/3, 7/4, 7/5, 7/6, 7/7 and 7/8/2020. -Blood pressure monitoring was blank on 6/11 through 7/1/2020. Resident screening/monitoring should have been completed once a day before illness was identified in the facility; twice a day once illness was identified in the facility; and increased to three times a day for ill residents (6/29/2020). F. Staff interview The NHA and the DCS were interviewed on 7/9/2020 at 1:10 p.m. They said they were not aware the staff was not monitoring all of the aspects of the COVID-19 screening requirements. The DCS said she would look into the identified issues.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Ensure staff were following proper hand hygiene procedures; -Provide hand hygiene opportunities for residents; -Ensure staff were following proper cleaning techniques for room cleaning. Findings include: I. Facility policies The Infection Prevention Overview policy, not dated, was provided via email by the nursing home administrator (NHA) on 4/1/2020. It read in part, prevention of spread of infection is accomplished by the use of hand hygiene standards of precautions. Staff and resident education focus risk of infection and practices to decrease risk. II. Failure to provide hand hygiene opportunities for residents A. Observations On 4/1/2020 at 8:13 a.m., certified nurse aide (CNA) #2 was observed to pass a tray to a resident on the North side. She failed to offer handwashing to the resident. On 4/1/2020 at 8:24 a.m., CNA #1 was observed serve the breakfast tray to Resident #1. The CNA set the resident's meal up, however, she failed to offer handwashing to the resident. On 4/1/2020 at 8:30 a.m., the physical therapist (PT) was observed to serve the breakfast tray to Resident #2. The PT failed to offer handwashing to the resident. On 4/1/2020 at approximately 8:45 a.m., the PT served the breakfast tray to Resident #3. The PT failed to offer hand washing to the resident. B. Interview The interim director of nurses (IDON) was interviewed on 4/1/2020 at approximately 4:30 p.m. The IDON said residents should be assisted with handwashing before and after meals. She said their were a variety of ways the residents hands could be washed. III. Clinical visit observation and interview On 4/1/2020 at 10:53 a.m. the nurse practitioner (NP) was observed visiting with residents and providing clinical assessments. She approached room [ROOM NUMBER] and placed on the floor outside of the room a bottle of germicidal disinfectant and a notebook with a pen. She entered the non-COVID-19 room with a stethoscope around her neck and the finger pulse oximeter. She washed her hands at the sink prior to donning gloves. Spoke to the resident in the room, asked the resident to stick out her tongue, asked the resident if she wanted water to drink. She auscultated the resident's lung sounds and abdomen with the stethoscope and placed the finger pulse oximeter on the resident's finger. When the assessment was completed the NP reached outside of the room and grabbed the pen and the notebook and wrote a note that she gave to the resident. She reached outside the room and from the floor sprayed the germicidal disinfectant on the finger pulse oximeter and the stethoscope. She grabbed a few towels to dry the finger pulse oximeter and the stethoscope at the sink inside the resident's room. The NP said there was not enough disinfectant wipes so she was using the germicidal spray and wiping the items off with towels. She said she wanted to keep the residents safe so she was not bringing her notebook or pen inside the rooms. She said she was going to enter a few of the rooms that were COVID-19 positive in a short while. Hallway 300 contained eight rooms and four of them were on COVID-19 precautions/isolation. The interim director of nurses (IDON) was interviewed on 4/1/2020 at 4:30 p.m. She said she would provide a clean surface for the NP to place the notebook, pen and bottle of germicidal disinfectant on to prevent from setting items on the floor causing a potential for cross contamination. IV. Observation of the cleaning of a resident's room and interview On 4/1/2020 at 12:35 p.m. observed housekeeper (HSK) #1 cleaning room [ROOM NUMBER]. CNA #3 translated during the discussion. HSK said she received COVID-19 training. The training included wearing a mask, frequent hand washing and keeping distance. She said she was told to use the germicidal disinfectant on the sink and frequently touched surfaces. She said she was assigned the rooms that did not have COVID-19 precautions/isolation. The housekeeping supervisor said that she provided the training to the housekeeping staff and devoted staff to COVID-19 positive rooms. The HSK was wearing a surgical mask and said she changed it at the end of the week or if it was difficult to breathe. HSK used alcohol based hand rub (ABHR) on the cleaning cart then donned gloves before entering the room. She emptied the trash and changed the trash bags in the double occupancy room. She sprayed the sink and the soap and towel dispensers with the germicidal disinfectant. She sprayed a rag with the germicidal disinfectant then wiped the handle on the entrance door front and back. She used the rag without reapplication of the germicidal disinfectant and wiped off the resident's bedside table, which was in front of the resident at the moment. The HSK wiped off the resident's water container, the television remote, then down the sides of the bedside table to the foot. She wiped off the handles on the dresser and across the top of the television. She then went back to the sink, soap and towel dispensers and wiped them off with the same rag as she used to dust the room. She rinsed the sink with water. She continued to use the rag and wiped off the handrails in the bathroom and the top of the toilet without reapplication of the germicidal disinfectant. She wiped off the mirror and then left the room to grab the toilet bowl cleaner and brush from the cleaning cart outside of the room. She then put the liquid toilet bowl cleaner in the bowl of the toilet. She used the toilet bowl brush to scrub the inside of the bowl, underside of the lid and then on the top of the seat. She used the same rag without reapplication of the disinfectant, wiped off the top of the toilet seat, down the sides of the toilet along the floor, then on the handrails and back to the top of the tank. She finished by putting the rag in a bag for dirty rags, swept and mopped the floor. The interim director of nurses (IDON) was interviewed on 4/1/2020 at approximately 4:30 p.m. She said the housekeeping staff were trained on what chemical should be used on the different types of surfaces. She said the housekeeper should have sprayed the surfaces that required disinfecting with the germicidal disinfectant spray then wait for three minutes before wiping the surface clean. She said the rag should not be used to wipe off surfaces without the surface being saturated with the germicidal disinfectant. She said the toilet brush should be used inside the toilet bowl and never on the outside.

Based on observations, record review and interviews, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for two (#1 and #2) of three residents observed for wound care of 15 total sample residents. Specifically, staff did not follow proper hand hygiene practices while providing wound care. Findings include: Facility policies The Wound Care/Treatment Guidelines policy, last revised February, (YEAR), was provided by the administrator in training (AIT) via email on 2/18/2020. It read in part, Hand hygiene should be performed. Supplies are not to be placed on the bed. Supplies should be placed on a clean surface. A blue absorbent pad or wax paper provides a clean barrier. The Hand Hygiene policy, last revised February, (YEAR), was provided via email by the AIT on 2/18/2020. It read in part, Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Policy: Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids. Using an alcohol-based hand rub (ABHR) is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, non intact skin, wound dressings; after removing gloves; and after contact with inanimate objects in the patient's environment. Observations On 2/11/2020 at 2:50 p.m. wound care observations for Resident #2 were made with registered nurse (RN) #1, who was the facility's wound nurse, and the wound care physician (WCP). RN #1 washed her hands and donned gloves then reached into the pocket of her scrub top for the wound cleanser bottle and a tube of wound ointment. Without changing her gloves, RN #1 then sprayed the wound cleanser on the wound and cleaned the wound with a gauze pad. Without taking off the gloves that she had just used to clean the wound, RN #1 proceeded to apply the wound ointment to the wound and cover it with a dressing. RN #1 then discarded the dressing supplies in the trash, and removed her gloves. She placed the wound cleanser bottle and tube of wound ointment back in her scrub pocket before washing her hands and exiting the room. At 3:15 p.m. wound care observations for Resident #1 were made with RN #1, licensed practical nurse (LPN) #2 and the WCP. RN #1 removed the old dressing from the coccyx and did not sanitize her hands or change her gloves after she removed the old dressing. Using the same gloves she used to remove the old dressing from the wound, RN #1 got the supplies she needed out of a plastic tub that was setting on the bedside table. She reached into her scrub pocket, pulled out the spray bottle of wound cleanser, and proceeded to cleanse the wound and apply a new dressing. She returned the wound cleanser to her scrub pocket. RN #1 then removed her gloves, used ABHR, and put on a new pair of gloves. RN #1 held up the resident's left leg for the WCP to assess the heel wound. After the assessment was completed, RN #1 reached into her scrub pocket again and removed the spray bottle of wound cleanser. She then proceeded to hand the spray bottle to LPN #2, who had not changed her gloves or performed hand hygiene after assisting with the positioning of the resident and prior to engaging with the wound. LPN #2 sprayed the wound cleanser on the left heel and RN #1 used a gauze pad to cleanse the wound. RN #1 took the wound cleanser back and returned it to her pocket. Resident #1 was having pain during the assessment of the wound on the top of the foot. The WCP, who had not changed his gloves and performed hand hygiene, reached into the pocket of his lab coat with his dirty gloves and proceeded to remove a spray can of numbing spray which he used on the wound prior to returning the can to his pocket. Upon completion of the assessment, RN #1 again reached into her scrub pocket, pulled out the bottle of wound cleanser, sprayed it on the wound, cleaned the wound with a gauze pad, and returned the bottle to her pocket without changing her gloves and performing hand hygiene. RN #1 then went to the plastic tub to get new dressing supplies. Without removing her gloves or washing her hands, she began searching through the tub for the supplies she needed. When RN #1 did not find what she needed, LPN #2 removed her gloves but did not perform hand hygiene before looking through the tub of clean supplies. RN #1 then removed her gloves, did not perform hand hygiene , and continued to look through the tub. Staff interviews RN #1 was interviewed on 2/11/2020 at 5:20 p.m. She said that hands should be washed before starting a dressing change. She said that gloves should be changed and hands sanitized after removing a dressing, after cleaning a wound, and beginning treatment on a different wound. She said that hands should be washed before leaving a resident's room. LPN #2 was interviewed on 2/11/2020 at 5:55 p.m. She said that she had worked at the facility for about nine months and had received hand hygiene training once during that time. She said she received the training upon hire when she was given handouts on hand washing to read. She said that if she was doing a dressing change she would wash her hands when she entered the room, put on gloves, and then wash her hands again before leaving the room. She said that if a resident had more than one wound, she would change gloves before moving from a contaminated body site to a clean body site. The director of nursing (DON), who was also the facility's certified infection control preventionist (ICP), was interviewed on 2/13/2020 at 9:00 a.m. The DON said that she performed random audits with staff, observing hand hygiene practices when she was out on the floor, and that she always reminded staff to wash their hands. She said she would do one on one education if she noticed a hand washing issue with a staff member. She said that the protocol for hand hygiene for nurses performing dressing changes would be for them to wash their hands before beginning the dressing change and then put on gloves. She said that nurses should change their gloves, use ABHR, and put on new gloves after removing a dressing. She said that they should change their gloves and use ABHR change gloves before moving from a contaminated body site to a clean body site. The DON said that she had been doing wound rounds with the WCP until a few weeks ago when RN #1 took over. She said she had observed RN #1 one time since she took over for wound rounds and had not noticed any concerns with her dressing change or hand hygiene practices. She said that staff was educated annually in regards to hand washing which included when to wash hands, how to wash, and when to wash with soap and water versus using ABHR to sanitize hands. She said that more education was needed with the staff. She also said that she would call the WCP and let him know of the infection control concerns, and inform him of facility expectations for hand hygiene and wound care practices.

Based on observations, staff interviews and record review the facility failed to ensure one (#12) resident of five residents sampled, with pressure ulcers, received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically the facility failed to prevent a delay in treatment for [REDACTED]. -Changing the treatment for [REDACTED]. -Ensure a qualified staff comprehensively assesses the development of Resident #12's wound to identify it was pressure injury timely; -Implement appropriate interventions after the development of the pressure injury timely; -Provide adequate tracking and monitoring of Resident #12's pressure injury, to include weekly wound measurements and a description of the wound, to promote wound healing; and -Obtaining an order on 11/6/19 for the wound doctor to assess the resident and having the initial wound doctor's assessment completed on 11/12/19 (14 days after the wound was identified). The failure to delay appropriate interventions for Resident #12 which caused the wound to worsen included not changing the treatment orders for eight days after identifying the wound, ensuring qualified staff assessed the wound initially and ongoing, implementing appropriate interventions upon identification, tracking and monitoring the development of the wound and not having the wound doctor assess the wound for 14 days after identification of the wound. As a result of these failures Resident #12's pressure injury on her coccyx worsened and developed into a Stage 3 pressure injury. Findings included: I. Facility policy and procedure The Skin Management Policy, revised (MONTH) (YEAR), provided by the minimum data set (MDS) coordinator (MDSC) on 11/20/19 at 4:50 p.m. It read in pertinent part: Residents received care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise are identified, assessed and provided treatment to promote healing, prevent infection and prevent new ulcers from developing. Ongoing monitoring and evaluation are provided for optimal resident outcomes. [NAME] Resident #12's status Resident #12, age 92, admitted on [DATE]. According to the computerized physician's orders [REDACTED]. The 10/29/19 MDS assessment documented the resident was cognitively impaired and was unable to complete the brief interview for mental status (BIMS). She required extensive assistance for all activities of daily living (ADL). The MDS indicated she was at risk of developing pressure ulcers and had one or more unhealed pressure ulcer at Stage 1 or higher; the stage was not indicated. She had moisture associated skin damage (MASD). She had a pressure reducing device for her chair and bed. The intervention included to apply ointments. The interventions did not include repositioning, nutrition, pressure ulcer care or applications of dressings. 1. Wound observation Resident #12's wound was observed on 11/20/19 at approximately 3:00 p.m. The resident had four approximate 1 cm (centimeter) diameter separate open areas to her sacrum in a total area of approximately 7 cm x 7 cm dark pink granulation tissue. Three of the open areas were to the right of the intergluteal fold superior, medial and inferior with the medial wound being approximately 20% slough in the wound bed. The superior and inferior wounds had pink granulation tissue in the wound bed. The fourth wound was to the left inferior intergluteal fold, with pink granulation tissue in the wound bed. The surrounding skin to all wounds was not blanchable. No drainage was seen. 2. Record review a. Care plan The skin integrity: pressure care plan revised 11/13/19 documented the resident had a pressure wound to the sacrum on 10/29/19 and had a Braden (assessment predicting pressure injury risk) score showing she was at risk for pressure related injury related to limited mobility, advanced age and incontinence. The goal was for the resident to not have any open wounds. Interventions included to assess/record/observe wound healing and measure the length, width and depth weekly. Other interventions included having an air mattress, a pressure reducing cushion for skin integrity, skin care per doctor's order, weekly skin checks and turn and reposition frequently to decrease pressure. The resident was referred to wound physician and treat per his recommendations, initiated on 11/13/19. b. Braden Scale for Predicting Pressure Sore Risk The 10/24/19 Braden Risk Scale indicated the resident was at moderate risk with a score of 14; at risk score 15-19, moderate risk score 13-14, high risk score 10-12, very high risk score nine or below. c. Skin assessments The 10/26/19 head to toe skin check did not indicate any type of skin issues on the coccyx. The 11/2/19 and 11/9/19 head to toe skin check documented the resident had three small open areas on the coccyx but did not include measurements, type, or a complete description of the areas. There was nothing documented to indicate MASD. The 11/16/19 head to toe skin check documented the resident had three small open areas on the coccyx but did not include measurements, type, or a complete description of the areas. In the notes section, foam dressing in place was documented. There was nothing documented to indicate MASD. d. Situation, Background, Assessment, Situation (SBAR) The 10/29/19 SBAR documented the resident had a change in condition with 3 open areas on resident coccyx area .5 cm diameter on all 3. Are cleansed cream applied to site, which started on 10/29/19. The SBAR did not include any description of the wound. e. Physician wound notes The initial consult dated 11/12/19 (14 days after the wound was identified) documented the physician was asked to see this patient for my opinion on how to manage the patient's wounds. The wounds were on the sacrum and were pressure related. The wound assessment, in pertinent part: Wound #1 Sacrum is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 7 cm length x 1 cm width x 0.1 cm depth, with an area of 7 sq (square) cm and a volume of .7 cubic cm. There is a light amount of drainage noted which has no odor. Wound bed has 50% slough, 50 % granulation. The periwound skin exhibited: Maceration. Comprised of 3 areas. The plan was to cover the wound with foam dressing - use [MEDICATION NAME] Ag and change every other day and a group 2: Low Airloss Mattress. The 11/19/19 wound progress note documented, in pertinent part: Wound #1 Sacrum is a stage 3 pressure injury pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3 cm length x 1.2 cm width x 0.1 cm depth, with an area of 3.6 sq (square) cm and a volume of .36 cubic cm. There is a light amount of drainage noted which has no odor. Wound bed has 100% granulation. The wound is stable. The periwound skin exhibited: Maceration. The treatment remained the same. f. Progress notes The 10/31/19 orders-administration note documented to monitor all areas of skin , barrier cream to open areas, areas with scant amt (amount) bloody drainage without odor. The 11/12/19 weekly pressure injury note documented the resident had a new pressure wound to sacrum, aggregate size 7.0 x 1.0 with 3 small open areas approximately 0.5 cm each. Some slough and some granulation tissue present. Surrounding skin is macerated. The 11/15/19 nutrition note documented, in pertinent part: nutrition continued follow up due to wounds: informed (resident name) has a new stg (stage) III pressure wound to sacrum. The director of nursing (DON) provided a progress note on 11/21/19 at 4:10 p.m. which documented late entry note: this note is a follow up note to the SBAR of 10/29/19. Resident observed with three small red areas .5 cm diameter. Appears to be moisture associated [MEDICAL CONDITION], reddened areas with no slough, not open at this time. To continue with barrier cream, for intervention. g. Certified nurse aide (CNA) tasks The CNA task, documenting whether the resident was on a turning program indicated from 10/21/19 through 11/19/19 during the day shift (6:00 a.m. - 6:00 p.m.) there were five yes responses (indicating she was on a turning program) and 22 no responses and two responses that were blank (not indicated). During the night shift (6:00 p.m. - 6:00 a.m.) there were 17 yes responses and 12 no responses. The CNA task documenting why the resident was not turned and repositioned from 10/22/19 through 11/19/19 documented response not required each day. The CNA task documenting if the resident was turned or repositioned documented during the day shift revealed the resident was turned or repositioned six times and response not required was documented 23 times, indicating she was not turned or repositioned. During the night shift the resident was repositioned 18 times during the night shift and response not required was documented 11 times during the night shift. h. Treatment administration record (TAR) The (MONTH) 2019 TAR documented the resident received weekly skin assessments every Friday in (MONTH) except on 10/18/19 where the TAR was blank. The (MONTH) 2019 TAR documented the resident was to receive buttock wound care: clean with wound cleanser. Apply Silver AG to the wound bed. Cover with foam. Every day shift for wound care. The order date was 11/6/19 and discontinued 11/14/19. The TAR indicated the treatment was missed on 11/8/19. i. Skin Assessments The incomplete 11/2/19 skin assessment documented the resident had three small open areas on the coccyx. There were no additional notes. The incomplete 11/9/19 skin assessment documented the resident had three small open areas on the coccyx. There were no additional notes. The incomplete 11/16/19 skin assessment documented the resident had three small open areas on the coccyx. There were no additional notes. The skin assessment forms had an area to describe an identified areas further to include a description of the site, type, length, width, depth and stage. In all three skin assessments this area was blank. There were no Skin - Weekly Pressure Ulcer Record Assessments completed for the resident since the identification of the residents open area on her coccyx on 10/29/19. j. Kardex (CNA documentation for understanding how to care for the resident) The Kardex documented the resident should be turned and repositioned frequently to decrease pressure but did not specifically define how often, to use barrier cream with incontinence care and encourage consumption of protein rich foods related to healing. B. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 11/19/19 at 3:00 p.m. She said she would do everything for the resident because she was unable to do anything for herself. She said when they changed the resident's brief they would put barrier cream on her bottom. She said they would attempt to reposition her every two hours and would attempt to keep track of this by repositioning two to three residents and then return to Resident #12. She showed the computer tasks screen but was unable to show that two hour repositioning had occurred for the resident. She confirmed repositioning was only indicated once per shift (see above tasks). The MDS Coordinator (MDSC) was interviewed on 11/19/19 at 3:25 p.m. She said that an order was obtained for Resident #12's air mattress on 11/14/19 but knew she had it before but was uncertain how long she had had it. She said it was not typical for the facility to get an order for [REDACTED]. She confirmed that Resident #12 only had barrier cream as a treatment for [REDACTED]. She said that the facility would obtain an order for [REDACTED]. The wound doctor was interviewed on 11/19/19 at 4:39 p.m. He said the first time he observed the wound for Resident #12 was on 11/12/19 and agreed he should have seen it sooner. He said this wound would have been avoidable. The MDSC was interviewed on 11/20/19 at 9:43 a.m. She said in an effort to prevent another wound, staff would increase skin care and increase monitoring and positioning. She agreed the CNA tasks were not clear and were canned tasks and said this was an opportunity for education. She said she would assume the CNAs completed the repositioning tasks but since it was not documented she could not confirm it actually had happened. She said it was hard to say how often it had actually happened (turning and repositioning), and agreed if there was an actual program it would have helped with prevention. The MDSC and the clinical consultant (CC) were interviewed on 11/20/19 at 10:54 p.m. The CC said she received a wound report every Friday from the director of nursing but had not received anything regarding Resident #12 until 11/14/19. The CC said it would depend on nursing judgement whether the wound doctor was involved or not but would have the wound doctor follow anyone that had any type of pressure injury. She said once the MASD was identified facility staff continued to use barrier cream, and continue turning and repositioning the resident. She said based on what the DON had told her she did not know there were any open areas to the coccyx but she could not say for sure whether there was a pressure injury or MASD when the 10/29/19 SBAR was created. The DON was interviewed on 11/21/19 at approximately 10:30 a.m. She said that when she originally looked at the resident's coccyx, on 10/29/19, there were only red areas but she did not document her observations. She said she entered a late entry into point click care (see above) on 11/21/19. She said between 10/29/19 and 11/6/19 staff continued to use barrier cream and turn and reposition the resident. She said an order was obtained from Resident #12's primary care physician on 11/6/19 (eight days after the area was identified) for the resident to be seen by the wound doctor. She confirmed the wound doctor came every Tuesday, therefore the wound was not evaluated by the wound doctor until 11/12/19. She said the treatment changed for the wound on 11/6/19 when orders were obtained.

Based on record review and interview, the facility failed to ensure the comprehensive care plans for two of 54 sample residents (#13, #96) were individualized and included measurable goals. The facility's failure to individualize resident #13's bowel elimination care plan contributed to the resident's hospitalization for bowel complications. The findings include: 1. Resident #13 Resident #13, a [AGE] year old male, was admitted to the facility, on 9/14/11. According to the resident's November computerized physician's orders [REDACTED]. An updated face sheet, provided, on 11/22/11, read that the resident's [DIAGNOSES REDACTED]. No minimum data set (MDS) information was available on this resident. a. Cross-reference F309; Quality of Care Resident #13 repeatedly complained about bowel issues and feeling as though he had a blockage. This continued for nearly a month (9/14/11-10/11/11) until the resident was sent to the hospital, was identified as having a sigmoid volvulus and received a [MEDICAL CONDITION]. The hospital discharge summary, dated 11/9/11, read in pertinent part: "This patient had a distended akinetic (without movement or without much movement) bowel. It was presumed that he had obstipation (severe constipation) and constipation but after careful evaluation it is quite possible that this patient has a sigmoid volvulus. Surgical consultation was obtained. After discussion with surgery and further evaluation, it was decided that this patient would benefit in the long-term with a left hemicolectomy (resection of the colon) and [MEDICAL CONDITION] (a surgical procedure where the end of the large intestine is brought out through the abdominal wall. Stool drains into a collection bag.) The patient agreed with the assessment from doctor and the patient underwent surgery on 10/19/11. A sigmoid volvulus was found and this area was resected and a [MEDICAL CONDITION] was placed." b. Facility Failure The facility failed to complete an individualized care plan that specifically addressed the history and needs of resident #13 in regard to his bowel protocol, resulting in ineffective interventions and bowel complications. The resident's care plan, dated 9/16/11, for bowel elimination listed the resident as having a problem of actual alteration in bowel function, with episodes of constipation related to decrease mobility. Under approaches; five boxes were checked, indicating that the facility would encourage fluids, administer medications as ordered, encourage activity, observe for bowel pattern to ensure adequate bowel elimination, and notify the physician as indicated. c. Interview In an interview with the director of nursing (DON), on 11/22/11 at 9:30 a.m., she was asked about the appropriateness of the resident's bowel elimination care plan considering his pre-existing issues and bowel issues. She responded, "The care plan is too generic for the resident's situation regarding his bowel problems." When asked if the facility had created a care plan that addressed the resident's needs she stated "No." 2. Resident #96 According to the face sheet, resident #96 was an [AGE] year-old male most recently admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), dated [DATE], showed the resident had moderate cognitive impairment. He required supervision with bed mobility, walking, locomotion, eating, toilet use, and personal hygiene. He required limited assistance with transferring and dressing. Record Review: The resident's activities care plan dated 9/15/11 showed, "(Resident #96) was born in (Texas). He and his wife have 9 children. He is the caregiver to his wife. They practice the Catholic Faith. (Resident #96) had a career as a farmer and attended school through the 6th grade. (Resident #96) anticipates a short stay and return home. His current interests are watching TV - westerns, football, baseball - listening to most music (no rap), the outdoors, talking, and religious offerings. (Resident #96) has a very supportive family and they visit frequently. In the past he enjoyed playing poker, taking trips, and gardening." The resident's activity goals as outlined on the care plan were: -Continue to make his leisure activity choices daily as he desires. -Will watch TV daily or as he desires. -Will continue to accept family visits daily as he desires or when they come. -Will continue to engage in conversation with staff as he desired. -Will continue his daily activities without showing signs of isolation but showing pleasure through verbal or facial expressions. Approaches: "Provide monthly activity calendar. Invite to activities of potential interest. Assist to and from activities. Invite to the activity room and introduce him to items for independent activity. Invite family to participate in a group function. Gain eye contact before communication. Speak slowly using clear defined words. Verify that communication has been understood. Use translator, if needed. Offer items for independent activity. Use appropriate praise for past and present accomplishments. Offer "Friendly Visits."" An Activity Progress Note, dated 9/15/11, read: Re-Admit Note: (Resident #96) has had no change in mental status that would affect his participation in activities. (Resident #96) has a supportive family and spends most his time with his wife. He also enjoys going to Catholic Services. His plan of care has been written on this day and will be reviewed in 90 days." Staff Interview: On 11/22/11 at 8:38 a.m., the activities director (AD) was asked to explain how she would measure the goals on resident #96's activity care plan. She stated, "I'm still getting the hang of this whole activity thing. I just try to care plan around what I see and what I observe and what they actually do." The AD acknowledged the current care plan did not include measurable goals and said she would revise the care plan. On 11/22/11 at approximately 1:00 p.m., the AD presented an updated activity care plan for resident #96. The new goals included: -(Resident #96) will continue to make his leisure activity choices daily. -(Resident #96) will continue to watch TV and socialize with his family and staff daily. -(Resident #96) will attend Spanish music socials 2x/month. -(Resident #96) will attend Catholic services 2x/week.

Based on record review and interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental or psychosocial level for six (#13, #128, #6, #130, #121 and #96) out of 54 sample residents. Specifically: -The facility failed to assess and monitor resident #13 when he continued to have complaints of abdominal pain, contributing to a decline in his bowel function and bowel complications. -The facility failed to accurately assess residents #128 and #130 post-[MEDICAL TREATMENT]. -The facility failed to follow policy and physician orders [REDACTED].#121's blood sugars were outside of parameters. -The facility failed to monitor resident #6 for [MEDICATION NAME] use. -The facility failed to properly transcribe and administer resident #96's pain medication. The findings include: I. Bowel Management A. Professional Reference According to the National Digestive Diseases information Clearinghouse, "Anatomical problems of the colon," February 2005, <http://digestive.niddk.nh.gov> (November 2011) "Sigmoid Volvulus," the sigmoid is the last section of the colon. Two anatomic differences can increase the risk of sigmoid volvulus. One is an elongated or movable sigmoid colon that is unattached to the left sidewall of the abdomen. Another is a narrow mesentery that allows twisting at its base. Sigmoid volvulus, however, can occur even without an anatomic abnormality. Risk factors that can make a person more likely to have sigmoid volvulus are [DIAGNOSES REDACTED], [DIAGNOSES REDACTED]s, and megacolon (an enlarged colon). Adults, children, and infants can all have sigmoid volvulus. It is more common in men than in women, possibly because men have longer sigmoid colons. It is also more common in people over age 60, in African Americans, and in institutionalized individuals who are on medications for psychiatric disorders. In addition, children with malrotation are more likely to get sigmoid volvulus. The symptoms can be acute (occur suddenly) and severe. They include a bowel obstruction (commonly seen in infants), nausea, vomiting, bloody stools, abdominal pain, constipation, and shock. Other symptoms can develop more slowly but increase over time, such as severe constipation, lack of passing gas, crampy abdominal pain, and abdominal distention. A doctor may also hear increased or decreased bowel sounds. Several tests are used to diagnose sigmoid volvulus. X rays show a dilated colon above the volvulus. Upper and lower GI (gastrointestinal) series help locate the point of obstruction and show whether malrotation of the rest of the colon is present. A CT scan may be used to show the degree of twisting and malrotation, and whether perforation has occurred. In most instances, a sigmoidoscope, a tube used to look into the sigmoid colon and rectum, can be used to reach the site, untwist the colon, and release the obstruction. However, if the colon is found to be twisted very tightly or is twisted so tightly that blood flow is cut off and the tissue is dead, immediate surgery will be needed to correct the problem and, if possible, restore the blood supply. Dead tissue will be removed during surgery, and a portion of the colon may be removed as well-a procedure called a resection. Sigmoid volvulus can recur after untwisting with the sigmoidoscope, but resection eliminates the chance of recurrence. Prompt [DIAGNOSES REDACTED]. B. Resident #13 1. Resident #13, a [AGE] year old male, was admitted to the facility on [DATE]. According to the resident's November computerized physician's orders [REDACTED]. The resident was discharged to the hospital on [DATE] with a firm, distended abdomen. He was readmitted [DATE]. His updated face sheet, provided on 11/22/11, read that the resident's [DIAGNOSES REDACTED]. No minimum data set (MDS) information was available on this resident. A resident care plan, dated 9/16/11 for bowel elimination, listed the resident as having a problem of actual alteration in bowel function, with episodes of constipation related to decrease mobility. Under approaches five boxes were checked, indicating that the facility would encourage fluids, administer medications as ordered, encourage activity, observe for bowel pattern to ensure adequate bowel elimination, and notify the physician as indicated. 2. Review of the nurses' notes revealed documentation of a firm, distended abdomen beginning 9/15/11. The notes read: -9/15/11 at 7:00 a.m., abdomen distended with b.s. (bowel sounds in all four quadrants), hyperactive. - 9/15/11 6:00 a.m. to 6:00 p.m., Abd (abdomen) dist (distended) firm ordered fleets mineral oil enemas and mag [MEDICATION NAME] (a laxative) from pharmacy. Illegible- res (resident) had small bm (bowel movement) with diarrhea on day shift. Res wants to talk to dietician re (regarding) meals. - 9/16/11 at 6:00 a.m., abdomen hard, distended, with hyperactive gurgly bowel sounds. -9/17/11 at 1:30 p.m. Resident able to make needs known. Admit (SIC) about his wishes. Has tendency to sulk if not getting his way. When given choices, res (resident) will freeze and not answer. Shakes his head, taps his fingers. At occurrence, left res alone for a max (maximum) of 15 min (minutes). Upon return was able to cont (continue) care. Res wishes to have 0800 (8:00 a.m.) med after breakfast. He wants food preferably fruit (banana) with his [MEDICATION NAME]. Stomach is distended but less hard than this time previous shift. PRN (as needed) suppositories are desirable and shall continue this evening. Positive results have been verbalized. -9/18/11 Res continent with use of urinal. Requested use of bed pan (positive) results at 0700 (7:00 a.m.). Abdomen distended and firm. Res demanding towards diet- very specific requests. -9/20/11 (potassium level low) new orders- resident fluids to 1500 cc due to low sodium level. Suppository given med (medium) results. -9/27/11 at 4:30 p.m. Res refused 0800 (8:00 a.m.) dose of [MEDICATION NAME] d/t (due to) 2 loose stools this morning. -9/30/11 Resident concerned (with) rigid abdomen. Abdomen firm with tenderness on lower (left) quad (quadrant). Supp (suppository) given with (positive) results on PM shift. This nurse believes that firm abdomen is r/t (related to) resident remaining tense. Earlier conversation as to when this feeling of a blockage began resident stated that it has felt this way since my brother visited on Wednesday. This nurse ensure(d) resident that he is safe here. -10/2/11 Resident states fear of blockage. -10/3/11 at 11:00 a.m., observed res only ate 2-3 bites of dry cereal. Res accepted a mighty shake and 2-3 bites of applesauce. Res expresses desire to have x-ray on bowels. States he does not feel well. Treating nausea all weekend. 10/7/11-6:00 a.m. to 6:00 p.m. (Physician) in for rounds this shift. To push fluids and push bowel regimen aggressively. Orocologist (SIC) will not address food tube until bowels are clear. -10/10/11- Resident continues behaviors r/t eating or drinking. Medication given crushed in applesauce. [MEDICATION NAME] accepted. Mighty shakes x3 given. BS present. Fear of blockage is unfounded as resident has been having regular BM's. Continual struggle to get resident to take anything by mouth. 3. Transfer to the hospital 10/11/11 - Discharge summary 11/9/11 On 10/11/11, nurses' notes read: (Physician) in for rounds this shift. After assessment of condition 10 lb weight loss, refusing (treatment), refusing to eat, received orders to transfer to (local hospital) for further treatment. Resident transported by in house services at (2:00 p.m.) Report was given to nurse, face sheet, MAR (medication administration record), progress notes and labs were given. The resident was transferred to the hospital on [DATE]. According to the transfer form, dated 10/11/11, [DIAGNOSES REDACTED]. Review of the hospital discharge summary, dated 11/9/11, revealed it read, in pertinent part: -This is a [AGE] year-old male who is admitted to the hospital with [REDACTED]. Charts revealed that he has lost about 8 or 9 kg (kilograms) in the last 2 months. The patient was sent to (local hospital) as a direct admit by (resident physician) for evaluation and management. -This patient had a distended akinetic (without movement or without much movement) bowel. It was presumed that he had obstipation (severe constipation) and constipation but after careful evaluation it is quite possible that this patient has a sigmoid volvulus (see professional reference above). Surgical consultation was obtained. After discussion with surgery and further evaluation, it was decided that this patient would benefit in the long-term with a left hemicolectomy (resection of the colon) and [MEDICAL CONDITION] (a surgical procedure where the end of the large intestine is brought out through the abdominal wall. Stool drains into a collection bag.) The patient agreed with the assessment from doctor and the patient underwent surgery on 10/19/11. A sigmoid volvulus was found and this area was resected and a [MEDICAL CONDITION] was placed. An attempt to interview the resident, on 11/16/11 at 2:11 p.m., was unsuccessful; the resident did not feel comfortable discussing his recent [MEDICAL CONDITION]. 4. Facility Failures (1) Failure to assess the resident's bowel status and notify the physician after 10/7/11 visit. Review of nurses' notes above revealed the resident continued with "behaviors r/t eating or drinking" and to express fear of bowel blockage after the physician visit 10/7/11. There was no documentation that the resident's bowel status was assessed by nursing staff or that the resident's behaviors and fear were communicated to the resident's physician until 10/11/11. (2) Failure to monitor the resident's bowel status. Interview with the director of nursing (DON), on 11/22/11 at 9:30 a.m., revealed that the facility was aware that the resident had a history of [REDACTED]. She stated that due to his history, the facility would expect the resident to have issues with his bowels in the future. When asked if the resident's history would make his bowel regimen and tracking an immediate concern to all nurses on the floor, she stated that it would. When nurses' notes were reviewed with the DON, she was asked if any of the notes would indicate that the resident was in need of further evaluation or if he was symptomatic of a bowel obstruction or obstipation. She stated that the resident's symptoms could be indicative of a bowel obstruction, or of his other diagnoses. Review of bowel and bladder shift chart, on 11/22/11, with the DON revealed the document was dated from 9/14/11 to 10/12/11, and had a line for each eight hour shift on each date. Out of 85 shifts documented, the resident only had 18 documented bowel movements. When the DON was asked to address the large span of shifts between documented bowel movements (some as great as 12 shifts), she stated that many of the entries were inconsistent with the nurses' notes. When asked where the discrepancies had occurred, she stated that they were having problems with the bowl and bladder shift charting. (3) Failure to develop an individualized care plan to address the resident's know risk for bowel complications. In an interview, on 11/22/11 at 9:30 a.m., the DON was asked about the appropriateness of the resident's bowel elimination care plan, considering his pre-existing bowel issues. She responded, "The care plan is too generic for the resident's situation regarding his bowel problems." When asked if the facility had created a care plan that addressed the resident's needs, she stated "No." II. Blood Sugar Monitoring Resident #121 1. Resident #121, a [AGE] year old male, was admitted to the facility on [DATE]. According to the resident face sheet, his [DIAGNOSES REDACTED]. 2. Diabetic Management Plan The resident's orders for diabetic management included: -According to the most recent computerized physicians orders, dated for November 2011, the resident was ordered to have accuchecks (for blood sugar levels) twice daily and if blood sugar was below 70 or above 400, the nurse was to call the physician. The start date of the order listing these parameters was noted as 7/17/11. The resident's care plan titled, " hypo/hyper glycemia" dated 7/12/11, identified the resident as a brittle diabetic and identified the physician prescribed parameters of 70 to 400 for blood sugar levels. The plan was reviewed on 8/4/11, 10/12/11 and 10/17/11. 3. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] MARs: -Note 10/1/11 held [MEDICATION NAME] bs (blood sugar)126 -10/6 held [MEDICATION NAME] bs 132 -10/7 held [MEDICATION NAME] bs 138 -10/14 held [MEDICATION NAME] bs 149 drops in am -10/18 - 7:30 a.m. held insulin bs 54 with initial reading. 119 after orange juice (only 119 on flow sheet) -10/19 - 11:00 a.m. held insulin bs 68 -10/24 did not give insulin as resident blood sugar low compared to baseline and he becomes symptomatic around 100. No call to physician documented -10/24/11 1700 (5:00 p.m.) held morning insulin for bs of 91 -10/25/11 held [MEDICATION NAME] bs at 77 -10/28/11 held [MEDICATION NAME] bs 91 -10/31/11 held insulin blood sugar 120 Nurses' note: A nurses note, dated 10/24/11, stated that medication held for breakfast and lunch as resident becomes symptomatic at around 100. Blood sugars 72 and 109 consecutively. Will continue to encourage snacks as resident refused most of lunch and alternate. Fax: A fax to the physician, dated 11/4/11, requested that the resident be re-evaluated for new insulin orders due to several high and low blood sugars, and that the insulin is often being held. The glucose tracking sheets were also faxed to the physician. 4. Facility Failures a. There was no documentation that the physician was notified, on 10/18/11 and 10/19/11, that the resident's blood sugar readings was below 70. Likewise, there was no documentation the physician was notified on 10/24/11, of staff observations that the resident becomes symptomatic at a blood sugar around 100. b. Monitoring Although review of the recent computerized physician orders [REDACTED]. to call the physician as less than 40 and greater than 400. 5. Staff Interview Interview with the DON, on 11/14/11 at 11:36 a.m., revealed that the expectation of the facility and nursing practice was that when blood sugars were outside of parameters they needed to notify the physician. When shown the orders and the conflicting blood glucose tracking form, she stated that her assumption would be that it was not noted correctly. She further added that 40 would be too low of a number, and that she would need to clarify with the physician. When asked about the note stating that the resident was symptomatic at 100 (see note from 10/24/11 above) the DON stated that she could review it. The DON stated that she was not aware of the error or the issue of the physician's orders [REDACTED]. III. Post-[MEDICAL TREATMENT] Care A. Facility Policy [MEDICAL TREATMENT], Care of Residents Admission and General Care 1. Review and ensure orders upon admission are received for follow-up [MEDICAL TREATMENT] center appointments, shunt care, diet and fluid restriction (physician discretionary). 2. Place a colored armband that indicates "No BP (blood pressure) this Arm" on the resident's arm that has the shunt. 3. A [MEDICAL TREATMENT] Communication Record is initiated and sent to the [MEDICAL TREATMENT] center for each appointment; ensure it is received upon return. 4. Provide routine AV Shunt Care and Monitoring per physician order [REDACTED]. Post [MEDICAL TREATMENT]/Ongoing Care: 1. Check vital signs every shift for the 24 hours post-[MEDICAL TREATMENT] or per physician's orders [REDACTED]. -Monitor for signs of postural [MEDICAL CONDITION]. Instruct resident to change position slowly for a short time to avoid dizziness and possible falls. 2. Upon return from [MEDICAL TREATMENT], the nurse will check for thrill and bruit twice during the shift for which the resident returned. The nurse will assess the condition of the access site for bleeding, redness, tenderness, or swelling. If any of these conditions are noted, contact physician and document findings. -If bleeding is noted, apply direct pressure until it is controlled. -A thrill is checked by lightly placing fingertips over access site and feeling for vibration. -A bruit is checked by placing a stethoscope over the shunt area and listening for blood flow. 3. Monitor resident for signs and symptoms of toxic or adverse medication reactions, especially residents on cardiac medications as these residents may become toxic rapidly. 4. Monitor lab work. Notify physician as ordered or when lab values are abnormal. -Hemoglobin and hematocrit values are generally lower overall than normal, and most physicians will usually look for symptoms (i.e., shortness of breath, dizziness, extreme tiredness). Documentation 1. [MEDICAL TREATMENT] Communication Record 2. Nurse's Notes - key documentation elements: -Vital signs -intake and output -Urine (color, quantity, odor, consistency, presence/absence of hematuria), -Change in voiding pattern -Presence/absence of catheter, -Weight gain or loss, abnormal lab result (BUN, creatinine, WBC, etc.), -Response to medication or treatment, -[MEDICAL CONDITION] localized or generalized), and -Diet and fluid restriction and response. Shunt Care -Location of shunt, -Signs and symptoms of infection (redness, swelling, excessive tenderness, and drainage), -Auscultate & palpate for presence of bruit or thrill, -Temperature and color of shunt site and surrounding skin, -Type of dressing change and response, and -Dressing condition [MEDICAL TREATMENT] (Pre-Post) -Method of Transportation -Medication given, and -Vital Signs. B. Resident Failures 1. Resident #128 According to the face sheet, resident #128 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], showed the resident required extensive assistance with bed mobility, dressing, walking, locomotion, dressing, toilet use, and personal hygiene. The resident had moderately impaired cognition. a. [MEDICAL TREATMENT] Management Plan According to the November physician orders, as of 10/4/11, nursing staff were to palpate AV (arteriovenous fistula) and check for thrill and bruit. However, the resident did not have an AV fistula; rather, he had a port for [MEDICAL TREATMENT] in his right chest. Specifically, the nursing admission assessment dated [DATE], read: "Resident arrived to facility from (the hospital) at 1600 (4:00 p.m.). Hx (history) of end stage [MEDICAL CONDITION], valve with port R (right) chest ...resident receives [MEDICAL TREATMENT]..." The resident's [MEDICAL TREATMENT] care plan, dated 10/6/11, showed the resident received [MEDICAL TREATMENT] three times per week on Tuesday, Thursday and Saturday. Approaches included: -Fluid restrictions: 1500 mL -Colored arm band on the arm that has the shunt indicated "No BP (blood pressure) this arm." -[MEDICAL TREATMENT] Communication Record is sent to the [MEDICAL TREATMENT] center with each appointment and return of form is ensured after appointment is completed. -VS checked every shift for 24 hours post [MEDICAL TREATMENT] per physician's orders [REDACTED]. -After return from [MEDICAL TREATMENT], check for thrill and bruit 2x per shift on day resident returned, then daily. -Monitor site for bleeding, swelling, redness or tenderness after pressure dressing removed. -Monitor for drug reactions. -Monitor lab work. -Notify MD as indicated. b. Facility Failures (1) See care plan above; the plan made no reference to assessing and monitoring the resident's port; rather, it directed staff regarding BPs in the resident's arm with the shunt. (2) Review of the nursing daily skilled summaries on the days the resident went to [MEDICAL TREATMENT] showed the facility's [MEDICAL TREATMENT] policy and the resident's care plan (to monitor 'site' for bleeding, redness, tenderness, monitor VS every shift) frequently were not followed. The summaries read: -10/11/11, "Lungs clear, BS x 4, reports of loose stool. Denies pain, makes needs known to staff. Call bell in reach. Res ambulatory with walker and standby assist. Res has exceptional appetite. Made request for double portions. No new orders. Res went to [MEDICAL TREATMENT] this shift." -10/13/11, "Lungs clear, BS x 4, denies pain. Held [MEDICATION NAME] d/t (due to) c/o (complaint of) loose stool. Ambulatory with front wheel walker and standby assist. Makes needs known to staff, socializes well. Appetite remains above adequate. Fluid restrictions observed. No [MEDICAL CONDITION]." -10/15/11 --1:00 p.m.: "VS 137/75 (blood pressure), 96.2 (temperature), 83 (pulse), 20 (respirations), 96% (pulse oximetry). C/o not feeling well in general, to [MEDICAL TREATMENT] at noon." --9:00 p.m.: "VS 152/82, 97.4, 85, 26, 94%. No c/o pain, calls for assistance, able to make needs known." -10/18/11 --1:30 p.m.: "Vital signs 140/09, P 78, T 98.2, R 20, 96% RA (room air).... Resident left for [MEDICAL TREATMENT] at noon. Resident took meds without difficulty." --9:50 p.m.: "VS 154/86, 979, 95, 16, 96%. Resident appears tired d/t [MEDICAL TREATMENT] today. Resident was cooperative, took meds with no problem ..." -10/20/11 --1:30 p.m.: "Vital signs 133/83, P 100, R 20, T 98.3, 94% RA ...Resident left for [MEDICAL TREATMENT] at noon, no further concerns." "VS 135/86, 99.0, 90, 17, 97% RA, alert and oriented. Seemed wore out d/t [MEDICAL TREATMENT], asking what blood sugar was. Cooperative, took med with no problem." -10/22/11 --2:00 pm. "Pt with no complaints of pain. No noted problems. To [MEDICAL TREATMENT] at 11:30 a.m." --9:00 p.m., "VS 159/78, 98.9, 91, 20, 96%. No c/o pain. No noted problems, able to make needs known." -10/25/11 --1:15 p.m., "Vital signs: 145/85, P 71, T 96.8, R 20, 98% RA ...Resident went to [MEDICAL TREATMENT] today at noon. No new concerns noted." --9:15 p.m., "Vital signs 142/69, 97.8, 95, 22, 98% RA. Resident was cooperative with meds. Resident appeared worn out from [MEDICAL TREATMENT].." -10/27/11 --6:00 a.m., "Has port lower right side of neck for [MEDICAL TREATMENT]." --1:00 p.m., "...Resident out to [MEDICAL TREATMENT] today." --7:20 p.m., "BP 147/80. P 81, T 97.4, R 24, 98% RA. Resident went to [MEDICAL TREATMENT] today. No c/o pain or discomfort." -10/29/11 --2:00 p.m., "To [MEDICAL TREATMENT] at 11:30, no V (vitals) d/t OOF (out of facility), no c/o of pain, able to make needs known." --9:00 p.m., "VS 173/90, 96, 83, 20, 97% RA, no c/o pain, no further nausea, no noted problems." -11/1/11 --1:00 p.m., "Vital signs 149/87, P 71, T 96.0, R 16, 97% RA. Resident to [MEDICAL TREATMENT] today." --4:00 p.m., "Resident returned from [MEDICAL TREATMENT], c/o diarrhea. Resident had loose stool. [MEDICATION NAME] held." -11/3/11 --1:00 p.m., "Vital signs 123/76, P 92, T 97.9, R 18, 94%. Resident out to [MEDICAL TREATMENT] for the afternoon. No further concerns." --9:20 p.m., "BP 132/79, P 82, T 984, R 20, 94% RA ...Back from [MEDICAL TREATMENT] late this afternoon with no c/o pain or discomfort ..." [MEDICAL TREATMENT] communication record present. -11/5/11 --1:00 p.m., "VS 119/71, 97.3, 72, 18, 95%, to [MEDICAL TREATMENT] at 11:30, no c/o pain, able to make needs known." --9:00 p.m., "VS 131/76, 96.8, 79, 18, 96%, no c/o pain, no noted problems, able to make needs known." -11/8/11 --1:30 p.m. "Vital signs 0800 BP 152/88, P 66, R 20, 98% RA, T 96.1. Resident is alert and oriented and able to make needs known. No c/o pain or discomfort noted this shift. Resident had good PO intake ..." --9:40 pm. "VS 136/75, 991, 82, 18, 96% RA. Resident returned from [MEDICAL TREATMENT], slept for 2 hours." -11/10/11 --1:00 p.m., "Vital signs 123/66, P 80, R 20, 93% RA, T 98.6 ...Resident out to [MEDICAL TREATMENT] today." --10:20 p.m., BP 133/70, P 96, T 100 degrees, R 18, 93% RA. Resident back from [MEDICAL TREATMENT], c/o pain to lower legs and presented with elevated temp. [MEDICATION NAME] given. Resident ate well for supper, no further complaints, lung sounds clear, pulses palpable, cooperative with all cares, drank fluid well. Sleeping at this time. Will monitor." -11/11/11 --6:00 a.m., "Resident with temp as above (100 degrees)" --1:30 p.m., "Resident alert and oriented, able to make basic needs known. Resident has had low grade fever. Vital signs T 100, P 87, R 20, BP 129/77, 94% RA. Resident has had c/o bilateral leg pain this shift with no relief. Port to R upper chest good. Resident also has c/o dysuria. Order received from PA (physician assistant) to send resident to urgent care for prompt evaluation with full labs. No [MEDICAL CONDITION] noted to lower extremities ....Resident transferred to urgent care by facility van." -11/12/11, 10:00 a.m., Called hospital, resident has been admitted ." (3) Record review revealed only one [MEDICAL TREATMENT] Communication Form present in the resident's record (on 11/3/11) for the dates above. c. Interview On 11/11/11 at 4:22 p.m., a licensed practical nurse (LPN) working on the south unit was asked how to check for bruit and thrill. She said, "I honestly don't know how." The LPN was asked if she was responsible for assessing any residents after [MEDICAL TREATMENT]; she indicated she was to assess resident #128. When asked what she did for resident #128 after he returned from [MEDICAL TREATMENT], she said she checked his vital signs, assessed for pain, and made him comfortable. She did not mention the resident's assessing or monitoring the resident's port. On 11/11/11 at 4:20 p.m., after the resident had been discharged to the hospital, a physician's telephone order was obtained, "Check bruit and thrill x 2 on shift res returns from [MEDICAL TREATMENT] and Q (every) shift. Check VS Q shift for 24 hours post [MEDICAL TREATMENT]. Assess site for bleeding, redness, tenderness, swelling after pressure dressing removed and every shift." On 11/11/11, a second order, obtained at 4:35 p.m., read no blood pressure was to be taken on the arm with the shunt. The pressure dressing was also to be removed six hours after the [MEDICAL TREATMENT] treatment. On 11/14/11 at 2:56 p.m., the director of nursing (DON) was asked if it was protocol to obtain physician orders [REDACTED]. She said, "I'm glad they obtained the order. It is our policy that that is what they are supposed to do (regarding post-[MEDICAL TREATMENT] care)." On 11/14/11 at 3:49 p.m., the south unit assistant director of nursing (ADON) stated the resident did not have an AV fistula, he had a port. She stated the resident was still in the hospital with a high temperature. When asked her expectations for post-[MEDICAL TREATMENT] care and assessment on a port, the ADON said, "We never access his port, we just check it. We check for signs/symptoms of infection. With a port, we should check for bleeding and [MEDICAL CONDITION] and that he doesn't have to have a lot of pain/swelling." On 11/14/11 at 4:32 p.m., the staff development coordinator (SDC) who wrote the telephone order on 11/11/11 to check for bruit and thrill 2X per shift after [MEDICAL TREATMENT] (see above) was asked about the order. She said she contacted the [MEDICAL TREATMENT] center and the physician as well to ask about the pressure dressing. She said they also put the bracelet on his arm to show where his shunt was. When informed the resident had a [MEDICAL TREATMENT] port and not a shunt, she said the orders obtained were per the facility policy. On 11/15/11 at 11:52 a.m., the SDC was asked if the nursing staff had received training or in-services specific to [MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] care. She said, "It's not one of our required in-services. I'm going to have to sit with the IDT (interdisciplinary team) to determine what we are going to do about that. We are obviously going to have to do education on that. . .It's going to be a huge education focal point." d. Hospital Report Resident #128 was discharged from the hospital back to the facility on [DATE]. -His discharge [DIAGNOSES REDACTED]. The discharge note read, in pertinent part: -"The patient presented to the emergency roiagnom on [DATE] from the facility) with fever, headaches, and body aches since the day before. He had been recently hospitalized with metabolic acidosis secondary to [MEDICAL CONDITION] and was started on [MEDICAL TREATMENT] at that time. He had also received [MEDICAL TREATMENT] on the day prior to presentation in the emergency room . While in the emergency room , he was found to have leukocytosis as well as elevated lactic acid. There was concern for infection of his [MEDICAL TREATMENT] catheter. As a result he was stated on (IV antibiotics). He was admitted to the hospital after that." 2. Resident #130 According to the face sheet, resident #130 was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) information was unavailable. a. [MEDICAL TREATMENT] Management Plan The resident's [MEDICAL TREATMENT] care plan, dated 11/1/11, showed the resident received [MEDICAL TREATMENT] three times per week on Tuesday, Thursday and Saturday. Approaches included: -VS (vital signs) checked each shift for 24 hours post [MEDICAL TREATMENT] or per physician's orders [REDACTED]. -Monitor site for bleeding, swelling, redness, or tenderness. -Monitor lab work, notify MD as indicated. -No blood pressure on shunt arm. -[MEDICAL TREATMENT] communication record is sent to the [MEDICAL TREATMENT] center with each appointment, and return of form is ensured after appointment is completed. -After return from [MEDICAL TREATMENT], check for thrill and bruit 2x per shift on day resident returned, then daily. -Blue colored arm band to indicate no blood pressure on this arm. b. Facility Failures Review of the nursing daily skilled summary showed the facility's [MEDICAL TREATMENT] policy and care plan was frequently not followed. -10/29/11, "Res(ident) A (alert) x 1. Large BM (bowel movement) this shift and resident repeatedly attempts to get up out of bed w/o (without assistance). Found walking unsteadily in hall ...Resident given cares this AM. Shaved and cleaned nails. [MEDICAL TREATMENT] at 1200. Bag lunch sent with resident. Lungs clear, BS (bowel sounds) present. No c/o (complaints of) pain or discomfort. Resident hard of hearing. Must see face/mouth when speaking to resident. Expecting resident to return from [MEDICAL TREATMENT] at 1600." -11/1/11, "...No c/o pain or discomfort [MEDICAL TREATMENT] today. Fistula clean, dry, no redness or warmth. Bruit present. Lungs clear. BS present, no [MEDICAL CONDITION] ..." -11/3/11, "Lungs clear, BS x 4, denies pain, returned from [MEDICAL TREATMENT] hungry and cold. Went to bed at 1700." -11/5/11, " ..Resident unable to stand and pivot. Sit to stand used to toilet resident [MEDICAL TREATMENT] communication sheet and meal sent with resident for [MEDICAL TREATMENT] ...Resident returned from [MEDICAL TREATMENT]." The resident was then hospitalized with an ankle fracture until 11/9/11. -11/10/11, "Resident to [MEDICAL TREATMENT] today. No c/o pain or discomfort." A [MEDICAL TREATMENT] communication record was present and completed. -11/12/11, "..Res returned from [MEDICAL TREATMENT] weak and disoriented. Res is not answering questions, looks into your eyes but shows no signs of comprehension but nods head at each encounter. 1700, meds given, res eye, hand, mouth coordination is not appropriate. When raising med cup or drinking cup to mouth, he misses and spills contents. Assistance was provided to consume meds. Neb(ulizer) tx (treatment) running. 1

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free from accident hazards as possible and that five of 54 sample residents (#54, #130, #18, #26, #21) received adequate supervision and assistive devices to prevent accidents. The facility failed to supervise, investigate and to take consistent steps to keep the residents safe from repeat falls with injuries. Residents #54, #130 and #18 experienced repeat falls contributing to fractures, as well as pain. The findings include: I. Failure to Adequately Supervise and Implement Safety Intervention. A. Expectations - Facility fall policy-fall management Newly admitted residents 1. Facilities will take a proactive approach for new residents and will consider new admissions at risk for falls until the resident is reviewed by the interdisciplinary team (IDT). 2. Upon admission, the admitting nurse will complete the Fall Risk Assessment and then weekly for three additional weeks. The nurse will also complete the initial Care Plan and address risk factors related to the resident on the Plan of Care and implement appropriate interventions as identified. 3. All residents will be assessed for risk quarterly, annually, and for significant change using the Fall Risk Assessment. The RADAR (PointRight) report will also be reviewed for any changes in condition. 4. New Admissions will be placed on the Falling star Program until reviewed by the IDT. 5. The IDT team will meet and determine if the resident is to continue on the Falling Star Program. 6. If determined by the IDT that the resident is at risk, the Falling Star will be continued and interventions in the Plan of Care will be updated. If the IDT determines the resident not to be at risk, the resident will be removed from the Falling Star Program. Fall Event 1. When a fall occurs, assess resident for injury. 2. The Licensed nurse will complete: a. Incident/Accident Report (Briggs); b. 24 Hour Report (Briggs); and c. Initiate the Interdisciplinary Post fall Review 3. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form. The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post-Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. 4. The nurse will communicate the resident fall to the IDT via the 24 hour Report (Briggs). 5. The IDT will review all resident falls within 24-72 hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. 6. Fall information will be added to the Electronic Care Management Board (ECMB). 7. The IDT then modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS Assignment Sheets/Care Kardexes are updated as appropriate. 8. The IDT will be responsible for placing and removing residents on/off the Falling Star Program. 9. The IDT will complete the Interdisciplinary Post Fall Review. 10. The In-House Communicator form (Briggs) should be used to make referrals to appropriate IDT members. IMPORTANT: A Change of Condition form must be completed, if indicated by resident assessment. 11. The Director of Nursing or designee will document falls on the Incident/Accident Report QA&A Log and the Individual Resident Fall QA&A Log as they occur and submit reports to ERMA as indicated. ERMA reports may be used, if desired, to complete tracking/trending reports for QA&A. Resident With Potential Head Injury 1. Complete all items listed under Fall Event (items #1-#10, immediately above). 2. Complete the Neurological Record per instructions. Falling Star Program 1. The Falling Star is a visual identifier/reminder program for staff to recognize and to be aware of residents determined to be at risk. 2. Visual identifiers will assist the facility staff as well as family and visitors to identify those residents that are at risk for falls, and to respond accordingly when the resident demonstrates a behavior that may be associated with an impending fall. 3. Placement on the Falling Star Program a. Newly admitted residents b. Residents identified at risk IDT determination - If resident is identified for the program, a falling star symbol will be placed on any or all of the locations below: a. Over the bed b. On assistive devices 1. Wheelchair 2. Walker c. Identification band Placement of the symbol(s) will be determined by each individual facility. 4. Removal from the Falling Star Program a. Determined by the IDT (makes final decision) b. Resident without falls for three months c. Resident identified as not at risk When the resident is removed from the program, a nurse (or designee) will remove Falling Star Symbols from the resident room, wheelchair, etc., and the Care Plan will be revised. 5. Each facility is responsible for implementing individualized interventions related to/for each resident's fall risk. 6. Residents that experience actual falls will be reviewed each week during the Care Management Risk Review Meeting. 7. The Care Management Risk Review committee members will review Weekly all residents with falls for documentation, compliance, and interventions. Each resident with a fall will be reviewed weekly X4 after each fall to ensure Care Plan interventions are effective. 8. After the Care management Risk Review Meeting, the IDT will perform the follow-up items assigned as indicated by the review. On 11/10/11 at 2:45 p.m. the director of nursing (DON) and the assistant director of nursing (ADON) for the North side were interviewed regarding charting protocol for the facility related to falls. They indicated that each time a resident has a fall, the nurse should complete an interdisciplinary (IDT) post-fall review, a change of condition form, an incident report and if the fall is un-witnessed, neurological assessments should be started. The resident should be placed on alert charting, which requires the nurses to chart every shift for 72 hours. B. Failure to Provide Adequate Supervision and Assistive Devices to Prevent Accidents with Injuries. 1. Resident #54 Resident #54, [AGE] years old, was admitted to the facility on [DATE]. According to the facility face sheet, the resident's [DIAGNOSES REDACTED]. According to the minimum data set (MDS), dated [DATE], the resident had short-term and long-term memory loss and moderately impaired decision making skills. She required limited assist of one for transfers, and extensive assist of one for toileting, personal hygiene and dressing. a. Known fall risk Review of the resident's fall risk assessment, dated 5/27/11, reflected the resident's fall risk score was 12 (the form reflects that any score over 10 is a high fall risk). On 7/14/11 and 9/5/11, the resident's fall risk score was higher at 17. A review conducted on 11/10/11 of the resident's fall care plan revealed the plan was dated 4/20/11. Interventions included: -place call light in reach -ensure that resident has proper footwear when ambulating -ensure that lighting in room will support visual mobility -orient resident to room environment -provide assistive device for ambulation, wheelchair -encourage resident to call for assistance when -getting out of bed -transferring to chair -all transfers b. Repeat Falls with Injury - Failure to adequately supervise and provide assistive devices to prevent repeat falls. 1. 7/30/11 - Early Morning Fall Review of the interdisciplinary post-fall review, dated 7/30/11, reflected that the resident had a witnessed fall while attempting to get out of bed. The interdisciplinary team (IDT) implemented a pressure alarm to bed and wheelchair. This intervention was added to the fall care plan 8/2/11. Review of the incident report, dated 7/30/11, revealed the resident's fall was at 6:15 a.m. The change of condition form was completed on 7/30/11. Review on 11/10/11 at approximately 12:00 p.m. of the nurses' notes (NN) section of the resident's medical record, reflected an entry on 7/16/11, then a line drawn through the NN and the next entry was 8/10/11. -There was no supporting documentation to reflect that the resident's fall in the NN, on either the day of the fall or for 72 hours post-fall, as expected. -A request made on 11/10/11 at 2:45 p.m. for NNs related to the fall on 7/30/11. As of 11/22/11 (survey exit), the NN had not been provided. Review of the incident/accident investigation follow-up form revealed that the summary of investigation documented that the resident slid from the bed to the floor, attempting to change her brief and that the fall was unattended. 2. 9/14/11 - Second Early Morning Fall Review of the interdisciplinary post-fall review, dated 9/14/11 at 7:00 a.m., revealed documentation that the resident was found on the floor on her hands and knees. The resident was in tears and complaining of pain at a 8/10 to her hip, knee, coccyx, and back. She denied hitting her head, and had increased pain and tenderness on palpation to her left hip. The resident was transferred to the hospital at 7:25 a.m. via ambulance. The summary of the IDT section reflected staff education and disciplinary action if needed. The form did not document whether the alarm was in place or sounding. Review of the incident/accident report, dated 9/14/11, documented that the resident had a fall at 7:00 a.m. The form did not state whether the alarm was in place or sounding. Review of the change of condition form, dated 9/14/11, documented that the writer overheard the resident's wheelchair alarm sounding and upon entrance to the room, the resident was found on the floor. Neurological records (neuros) were initiated on 9/14/11. Review of the incident/accident investigation follow-up form documented the resident was getting dressed when she fell . The recommendation/new interventions form documented staff was educated that the resident needed help getting dressed. Review of the NN, dated 9/14/11 with no time for the entry, documented that the resident remained on neuros from fall. There was no supporting documentation to reflect that 72 hours post-fall charting was completed after one brief entry on 9/14/11, as expected. The next entry in the NN was 9/28/11. Failures: This was the resident's second early morning fall while engaging in self-care (changing brief, getting dressed). Although a care plan addition 8/1/11 directed staff to encourage resident to obtain assistance for transfers and ambulation, this intervention did not alert staff of the need to assist and supervise the resident in the early morning. 3. 10/10/11 - Third Early Morning Fall with Injury and Pain Review of the incident/accident report, dated 10/10/11 at 6:00 a.m., documented the resident was found on the floor in a pile of blankets. Resident stated that she rolled out of bed, hitting (her) left side on floor with a laceration to left eyebrow. The form reflected that the resident was not sent to the hospital. Review of the interdisciplinary post-fall review form, dated 10/10/11 at 6:00 a.m. revealed, however, that the resident was sent to the emergency room for evaluation and treatment. Review of the incident/accident investigation follow-up form documented the resident was sent out to the emergency department for severe head/neck/spinal pain and a crash mat was added to the resident's bed side at bedtime. These interventions (hospital transfer and crash mat) were added to the care plan 10/10/11. Review of the NN on 11/10/11 at 12:00 p.m. from 10/10/11 through 10/13/11, documented no change of condition form was completed for this fall. Review of the NN, dated 10/10/11 at 1:45 p.m., documented the resident returned from the emergency department with a [DIAGNOSES REDACTED]. -The NN further documented the resident was confused, requesting to "go home." She was complaining of pain, was medicated for pain, attempting to stand up from chair and to remove cervical (c) collar. The resident was moved into the nurses' station for closer monitoring, a sitter was requested, as well as a new bed. The DON was aware of need for sitter. -The NN read that the family was in and provided 1:1 during part of shift and the resident was at the nurses' station to prevent her from standing up and removing c-collar. Failures: There were no updates to the fall care plan to ensure a consistent increase in supervision of the resident or to monitor the status of the c-collar in place to address her cervical fracture. 4. 10/25/11 Fall Review of the NNs, dated 10/10/11 through 10/25/11, documented several incidents (10/10/11, 10/11/11, 10/12/11, 10/21/11, 10/24/11, and 10/25/11 - see below) where the resident was documented as restless, removing the c-collar, walking unattended, with no indication of alarms sounding. The resident was, at times, positioned close to staff for increased monitoring. -On 10/10/11 (no entry time), NN documented that the resident was at the nurses' station to prevent standing up and removing c-collar. -On 10/11/11 at 3:00 p.m., NN documented that the resident was agitated and pulling at c-collar. -On 10/12/11 at 2:00 p.m., NN documented that the resident continued to try to remove c-collar at 8:00 a.m., the resident was found in bed with c-collar on the floor, resident in nurses' station majority of the shift for supervision. -On 10/21/11 at 9:47 a.m., NN documented that the CNA heard the resident yelling in her room at 6:30 a.m., upon entering the room, the resident was found in her bed with her head turned to the side and the c-collar on the floor. -On 10/24/11 on 2-10 shift, NN documented resident was restless this shift and was one on one with nurses. -On 10/25/11 at 10:00 a.m., NN documented that the resident was extremely agitated in the morning, trying to remove c-collar, and the resident stated that she was ready to die. --The NN read that social services notified and she was evaluated related to the suicidal thoughts. Fifteen (15) minute checks were initiated. The resident spent two hours with a one on one with two certified nurse aides (CNA). The resident then moved to the nurses' station calm and resting in wheelchair. --The NN further read that one on one supervision would be continued during 2-10 shift, although the entry also documented the resident was on 15 minute checks for the entire shift, was agitated and messing with the c-collar most of shift. Review of the interdisciplinary post-fall review, dated 10/25/11 at 10:20 p.m., documented the resident's alarm was sounding and the staff went to the room and found the resident walking in her bedroom without the c-collar on. The resident fell head first onto the ground. The summary of the interdisciplinary team revealed mitts and an as-needed seatbelt be implemented and a care conference was to be held on 10/26/11 with family. Review of the NN, dated 10/25/11 with no time entry, documented that the resident was left unattended in her room and was found by the staff, when alarm started sounding, walking in her room without a c-collar on. She had a fall, head first, to the ground. The resident was sent to the emergency department for evaluation and treatment. (There was no documentation of additional injury.) Review of the fall care plan revealed that on 10/27/11, 15 minute checks, a care conference with family and physician, mitts, and an as needed seatbelt were added. 5. 11/1/11 Fall Review of NN dated from 10/26/11 through 10/31/11, revealed daily documentation of resident anxiety with little to no relief, one on one supervision, and/or close supervision at the nurses' station because of her fall risk, anxiety, and agitation. Review of the incident/accident report, dated 11/1/11 at 9:00 p.m., documented the resident bumped her head and left eyebrow. Review of the interdisciplinary post fall review form documented that at 9:15 p.m. (11/1/11), the resident stood up unattended and had a fall in the lobby. Her alarm did not sound until the resident was already on the floor. The summary of the interdisciplinary team documented that the staff was educated on toileting the resident every two hours, that the resident will get a broda chair next week and that an alarm was in place. Review of the NN dated from 11/1/11, the facility failed to complete the charting guidelines for a post fall (every shift for 72 hours). Failure: Although aware of the resident's fall risk, anxiety, and agitation, the facility failed to ensure the resident received adequate supervision to prevent another fall. -Review of the NN, dated 10/29/11 for the 6 a.m.-2 p.m. shift, revealed the self releasing seatbelt, planned after the 10/25/11 fall, was not available to be used as ordered and the charge nurse was notified. There is no further follow-up documented in the NN related to the seatbelt being made available to help keep the resident safe. -Review of the documentation above revealed no documentation that the resident's alarm -was re-evaluated to ensure it would be effective with movement, but prior to a fall. 6. 11/6/11 - Fall Review of the interdisciplinary fall form, dated 11/5/11, reflects a potential fall occurred on the 2 p.m.-10 p.m. shift, the resident was on the foot pedals when the nurse spotted her. There was no signature on the form and no other additional information. Review of incident/accident reports revealed a form filled out on 11/5/11 and 11/6/11. The information on each of them was the same; the form, dated 11/6/11, had a registered nurse's and the DON's signature. The 11/5/11 form had only the DON's signature. Review of the investigation follow-up documented the fall date as 11/5/11, and 11/7/11 for the date of investigation. The form revealed a CNA reported that the resident had a fall on the 2-10 shift while she was at the nurses' station with a licensed practical nurse (LPN) who was providing a one on one with the resident. The form was signed by the DON. Review of the investigation follow-up form, dated 11/10/11, investigating a fall 11/6/11, revealed a potential fall may have occurred on the evening shift, the resident may have fallen on her foot pedals, still under investigation. There was no signature on this form. The change of condition form was not completed and the resident was not placed on 72 hour post fall charting (even after the facility was notified). Failure: There was no indication in the documents above detailing the circumstances that led to a fall while the resident was on one to ones with the LPN on 11/5/11. Moreover, there was no indication why the fall 11/6/11 was a "potential" fall. Finally, there was no documentation that revealed fall interventions were re-evaluated and new interventions considered in an attempt to keep the resident safe. c. Observations On 11/10/11 at 11:35 a.m., the resident was observed in the common area by the nurse's station. She was sitting in a geri-chair that was reclined with a lap tray on it. The resident was wearing a cervical collar. On 11/10/11 at 10:30 a.m., the resident's room was observed. Her bed was positioned at standard height, up against the wall. A "crash mat" with sloping borders, which made it thicker in the middle, was on the floor. The center of the mat was approximately one-fourth to one-half an inch thick; it had a hard surface and did not appear softer than the floor in the resident's room. d. Interview On 11/10/11 at 2:45 p.m., the director of nursing (DON) and the assistant director of nursing (ADON) for the North side were interviewed. -The DON indicated that resident #54 had not had a medication regime review specifically related to the falls and that her toileting schedule, or daily schedule had not been reviewed specifically related to the falls, even though three of the five falls happened between 6 a.m. and 7:00 a.m., and two post fall reviews indicating some relation to being toileted or needing to be changed. -The DON was asked why the seatbelt had not been placed on the resident's chair when ordered 10/27/11. She stated she was not sure, and would have to investigate. She indicated that an as-needed seatbelt was not really an appropriate intervention; a seatbelt, if ordered, should always be on for the safety of the resident because one can't really tell when you might need it and then move to fasten it right away. 2. Resident #130 Resident #130, a [AGE] year old male, was admitted to the facility on [DATE]. According to the face sheet, his [DIAGNOSES REDACTED]. The Minimum Data Set information was unavailable for this resident. a. Known Fall Risk The resident's fall care plan, dated 10/31/11, showed the resident was at risk for falls related to his being a new admission, mental status, poor vision, balance problems, assistive devices, change in gait pattern, narcotics in use, and end stage renal disease. Approaches included, "Falling star program, encourage resident to ask for assistance, ensure that resident has proper footwear as indicated and accepted, interdisciplinary referral, orient resident to room/environment, provide assistive devices (wheelchair/front wheeled walker) as indicated and accepted, bed alarm - pressure (11/1/11), place call light within reach, place frequently used items within reach, crash mat/grippy socks." The resident's cognition care plan, dated 10/31/11, showed the resident was alert and confused. He had short/long-term memory loss and impaired decision making skills related to dementia. Approaches included: "Address resident by preferred name. Introduce self and explain procedures. Encourage and allow resident to assist with ADLs (activities of daily living). Allow resident to make as many choices and decisions as possible. Orient resident to time, place, date and activities as needed. Allow resident time to process information and respond. Repeat questions or comments as needed. Monitor changes in behavior. Assess for safety." The resident's hemodialysis care plan, dated 11/1/11, showed the resident received dialysis three times per week on Tuesday, Thursday, and Saturday. Approaches included, "VS (vital signs) checked each shift for 24 hours post dialysis or per physician's orders [REDACTED]." b. Falls following Admission - Facility Failure to Prevent Repeat Falls Review of the nurses' notes, hospital records, and physician orders [REDACTED]. Record review revealed: -The facility failed to ensure the resident was adequately monitored after dialysis. The falls on 11/1/11 and 11/10/11 occurred shortly after the resident had returned from dialysis at 6:00 p.m. and 5:00 p.m. respectively. -The facility failed to ensure the plan to monitor and toilet the resident was added to the care plan and failed to ensure planned interventions (grippy socks) were implemented. (1) 11/1/11 First Fall in Bathroom According to the nursing daily skilled summary, dated 11/1/11: -"Resident to ortho phys for dressing change to L hand/fingers. No c/o pain or discomfort. Dialysis today. Fistula clean, dry, no redness or warmth. Bruit present. Lungs clear, BS present, no edema. Some confusion noted. Resident failed to use call light when returning to bed from restroom. Lost balance near bed- Found on bottom near bed. Incident/accident report completed, faxed and phoned to phys(ician)." -11/1/11 5:00 p.m., "Resident was given instruction to use the call light before getting back in bed from using the toilet. He failed to do this and lost balance while walking back to bed. No apparent injury. Neuros intact. VS WNL. No c/o (complaints of) pain or discomfort. Large bruise on L (left) hip was d/t (due to) previous injury at home. Phys notified at 1705 (5:05 p.m.). Daughter notified @ 1710 (5:10 p.m.). Incident/accident reports faxed to phys office. Resident education given regarding the use of the call light and non-skid foot wear provided for resident. Aides notified to monitor resident and assist to toilet q2h (every two hours)." The Interdisciplinary (IDT) Post Fall Review read: 11/1/11, 5:00 p.m. Vital Signs: Temperature 97, Pulse 73, Respirations 22, Blood Pressure, 120/72. Summary of IDT: Crash mat to be added. Pressure alarm on bed, Falling Star, Grippy Socks. The Incident/Accident Report read, "Resident was to use call light in restroom before transferring back to bed. He failed to do this and lost balance, falling in front of bed. No apparent injury." IDT Meeting Notes 11/3/11 read, "CMRR (fall committee) met to review fall on 11/1/11. Interventions added are crash mat, pressure alarm, grippy socks, and falling star program. No further falls at this time. Res is also a new admit - [DIAGNOSES REDACTED]. Res goes to dialysis 3x/week. No skin issues. Renal diet and fluid restriction." Failure: The plan for aides to monitor the resident and to assist him to the toilet every two hours was not added to the resident's fall risk care plan. (2) 11/5/11 Second Fall in Bathroom - with injury (fracture) According to the nursing daily skilled summary: -11/5/11: "...5 a.m. lying on floor in front of bathroom floor. Stated slipped and fell and laying on left side. C/o left ankle (pain), +3 edema. Dr notified, x-ray ordered." -11/5/11: "Resident on neuros d/t early morning fall. X-ray ordered for L ankle/hip. Resident unable to stand and pivot. Sit to stand used to toilet resident. Neuros WNL. Dialysis communication sheet and meal sent with resident for dialysis. Radiology called and will be here immediately following dialysis." -11/5/11, 5:30 p.m., "Resident returned from dialysis. L ankle swollen and tender. Norco given. Medication effective. Still waiting for radiology." -11/5/11, 5:45 p.m., "Radiology here. X-rays taken. Tech assured this nurse that report would be generated ASAP (as soon as possible), that we should expect a report by 1930. (7:30 p.m.)." -11/6/11: "Received x-ray reports at 9:30 p.m. 9:50 p.m., said reports called to MD on call and new orders. Lt ankle very swollen and tender to the touch. Denied need for pain medication. Pt sleepy, had dialysis today. Easily aroused. Oriented x3. Was told not to get OOB (out of bed)/bear wt on LLE (left lower extremity). Secondary to swelling and x-ray reports ...Pt to ER approx 11:30 p.m ..." Radiology Results (date of service: 11/5/11, 7:12 p.m., signed 9:35 p.m.) revealed the resident sustained [REDACTED]." The report further read, "There may be a nondisplaced fracture of the medical malleolus. Evaluation is somewhat limited. There is diffuse soft tissue swelling." The Resident Transfer Form, dated 11/5/11, 11:30 p.m. documented the resident was transferred to the hospital for "Fx distal fibula + questionable medical malleolus." The Hospital History and Physical (dated 11/6/11), read, in pertinent part, "brought to the ER per EMS with chief complaint of fall and left leg pain. The patient states it happened early this morning. He slipped on the floor and immediately started left leg pain, which was located at left hip and left ankle area. X-ray was done, which showed left tibia and fibular fracture. Orthopedics was notified at the ER. The patient had a splint placed on the left lower leg. We will admit the patient for acute care." (The resident returned to the facility on [DATE].) Interdisciplinary Post Fall Review (dated 11/5/11) read: -"Possible fx (fracture) of ankle on left. Question hip injury. Lying on floor in front of BR (bathroom) urine on BR floor. States landed on floor on left side when slipped. Left ankle swollen, left hip tender, night gown on, bare footed, walker on side." -Summary of IDT: "Res OOF (out of facility) to ER for evaluation and treatment. Therapy caseload, crash mat, bed alarm, non-skid grippy socks, falling star." Incident/Accident Report read: "Resident lying on floor in front of bathroom floor. Had been to bathroom using walker - urine and feces on floor. Slipped landing on left side. Unable to put pressure on left foot. States just fell . Barefooted, night gown on. No briefs on." Incident/Accident Investigation Follow-Up read: Summary of Investigation: Res self ambulate to BR. Slipped in urine, not wearing socks. Recommendations/New Interventions: Res OOF to ER for eval. Failure: The facility failed to ensure a planned intervention (grippy socks) was implemented. On 11/05/11, the resident fell after presumably slipping in urine while barefoot. He was not wearing the non-skid socks. There was also no evidence the pressure alarm was in-place as it was not sounding after he got up from bed. (3) 11/10/11 Fall From Wheelchair According to the nursing daily skilled summary, dated 11/10/11: -"Resident to dialysis today. No c/o pain or discomfort. Phys ordered cxr (chest x-ray) and duonebs TID (three times per day) d/t low pulse ox, hypoxia. 1800 (6:00 p.m.), resident tried to get out of w/c (wheelchair) in order to get back to bed. He was laying in front of closet with no apparent injury. Lungs clear, BS present, no edema, no bruising to limbs or head. Resident stated that he was okay. VS WNL. Phys notified at 1805, family notified at 1810. Resident education given regarding the call light and asking for help when needing to ambulate. At time of fall, crash mat was not next to bed d/t resident being in w/c. Once put back to bed, pressure alarm in place, crash mat along side of bed, bed in low locked position. Neuros intact. Fall precautions in place. Call light in reach." The Interdisciplinary Post Fall Review (11/10/11, 6:00 p.m.) read: -"Resident tried to get out of wc in order to get back in bed. He was laying in front of closet. No apparent injury. Resident stated he was okay." -Vital Signs: Temperature 98.2, Pulse 85, Respirations 16, Blood Pressure, 96/63. Summary of IDT: "Pressure alarm to be added to wheelchair. In-service to staff." Incident/Accident Investigation Follow-Up read: -Description of incident/accident: "Resident tired to get out of w/c in order to get back in bed. He was laying in front of closet, no apparent injury." -Summary of Investigation: "Resident tried ... " (no further documentation) -Past Interventions Attempted: "Grippy socks, pressure bed." -Recommendations/New Interventions: "Pressure alarm to be added to wheelchair. Inservice to staff on alarm and call light placement." Review of the facility in-service revealed it read, "(Resident #130) will need to have his pressure alarm moved from his bed to his wheelchair whenever he is up. It needs to be moved back once he goes to bed. Please make sure call light is in reach." Fall Intervention Summary read that after the 11/01/11 fall, the resident was to wear non-skid socks and a pressure alarm was to be applied to his bed. Failure: The resident fell twice (11/1/11 and 11/10/11) after dialysis. There was no documentation that staff had considered increasing supervision of the resident following dialysis; no interventions were added to the care plan regarding the resident's known increased risk for falls following dialysis (see staff interviews below). c. Staff Interviews - Knowledge of resident's increase risk for fall On 11/14/11 at 2:25 p.m., the nurse present during resident #130's fall on 11/10/11 was asked about the fall. The nurse stated, "His crash mat was up because he was in his wheelchair. He got back from dialysis about 5:00 p.m. We offered to get him to bed but he wanted to sit in his wheelchair and watch television. The next thing we knew, he fell . We think he wanted to get back into the bed on his own. I told him, please pull the call light and we can assist you back to bed, to the bathroom, etc. and he's not compliant with that." When asked if she had assessed him or