Every finding on record at Winding Trails Post Acute

Based on observations, record review and interviews, the facility failed to ensure three (#2, #11 and #12) of twelve residents were kept free from physical abuse out of twelve sample residents.Specifically, the facility failed to:-Protect Resident #2 from physical abuse by Resident #3;-Protect Resident #11 from physical abuse by Resident #3;-Protect Resident #12 from verbal abuse by Resident #3; and, -Protect Resident #12 from physical abuse by Resident #1. Findings include:I. Facility policy and procedureThe Abuse, Neglect, and Exploitation policy and procedure, dated February 2023, was provided by the director of nursing (DON) on 10/2/25 at 3:50 p.m. It revealed in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff-to-resident abuse and certain resident-to-resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; establish policies and procedures to investigate any such allegations; includes training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management, and resident abuse prevention; and establish coordination with the Quality Assurance and Performance Improvement (QAPI) program. The facility will designate an abuse prevention coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.II. Incident of physical abuse by Resident #3 towards Resident #2 on 8/12/25A. Facility investigationThe 8/12/25 facility investigation documented Resident #2 suffered physical abuse when Resident #3 hit Resident #2 on his cheek and pulled his beard when both residents came back into the building from the smoking patio. Staff members witnessed the incident and separated the residents immediately. Resident #2 was assessed by a charge nurse and did not experience any pain or injury.The incident was reported to the police, the residents' families, the physician, the ombudsman, and adult protective services. Both residents were placed on frequent checks, and an investigation started. Resident #2 did not experience any fear following the incident and did not know why he was hit. Resident #3 denied knowing the reason for the contact and could not recall the incident. B. Resident #3 (assailant)1. Resident statusResident #3, age [AGE], was admitted on [DATE]. According to the September 2025 computerized physician orders (CPO), the diagnoses included type 2 diabetes mellitus and schizophrenia (mental disorder).The 7/18/25 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of nine out of 15. She was independent with toileting, and required set up assistance for transfers. 2. Record reviewThe behavior care plan, dated 1/28/25, documented Resident #3 had behavioral symptoms, including delusions and hallucinations. Resident #3 also had a history of refusal of care, sexual statements, odd statements, outbursts of thoughts, and yelling at other residents. The care plan documented most behaviors were directed towards males. Resident #3 refused consent to receive psychiatric services and said that she deals with her problems by journaling or being outside. Resident #3 also had a history of making false accusations. Interventions included activities assessment for diversional activities; encourage the resident to write in her journal when she appeared to be upset; encourage her to not take off her clothes in public; notify physician, responsible party of episodes of aggression and abusive behaviors; observe and document changes in behavior, including frequency of occurrence and potential triggers; observe for clinical factors influencing behavioral indicators (infection, pain, hypoglycemia, hyperglycemia, fever) and notify physician if observed; observe resident's mood and response to medication; observe whether the behavior endangered the resident and/or others and intervene if necessary; and redirection when this resident began to yell out at others and remove her from others when she begins this behavior.The 8/11/25 progress note documented an incident where Resident #3 threatened to castrate a male resident; they were separated and had no further opportunity for contact. Another incident was documented where Resident #3 wrote notes about cutting off penises; the staff confirmed there was no physical contact of any form between Resident #3 and other residents. 3. Resident interviewResident #3 was interviewed on 9/30/25 at 1:45 pm. Resident #3 said she got along with the females only. Resident #3 said she did not talk to men because she did not like most people. Resident # 3 said she did not know anything about incidents with male residents because she managed her own business and did not talk to males.C. Resident #2 (victim)1. Resident statusResident #2, age less than 65, was admitted on [DATE]. According to the September 2025 CPO, the diagnoses included schizoaffective disorder bipolar type, type 2 diabetes mellitus, diabetic neuropathy, major depressive disorder, post-traumatic stress disorder (PTSD, and a personal history of traumatic brain injury. The 7/15/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with transfers, bathing and dressing. 2. Record reviewThe behavior care plan, dated 1/15/24, documented Resident #2 had a history of altercations where he was the victim. He also had delusions, rejected care, and had verbal behavioral symptoms directed toward others. Interventions included observation and documentation of changes in behavior, including frequency of occurrence and potential triggers, observation of behaviors that endangered the resident (intervene if necessary removing others from the surrounding area), reduction of stimulation (noise, crowding, other physically aggressive residents) to the extent possible, and the resident was referred to psychiatry services.3. Resident interviewResident #2 was interviewed on 9/30/25 at 1:58 p.m. Resident #2 said he had incidents with Resident #3 three times. He said he thought she did it because she was delusional.Resident #2 said that Resident #3 threatened him and told him she was going to cut him into small pieces or kill him in his bathroom. Resident #2 said that he was worried about other residents because she was dangerous, and he had to place a chair behind his room door. Resident #2 said Resident #3 hit other residents in the facility, including Resident #11. Resident #2 said he reported all these incidents to the staff. III. Incident of physical abuse by Resident #3 towards Resident #11A. Resident #11 (victim)1. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, the diagnoses included type 2 diabetes mellitus, unspecified dementia, psychotic disturbance, mood disturbance, major depressive disorder, anxiety, and heart failure.The 9/8/25 MDS assessment revealed the resident was moderately cognitively impaired with a BISM score of 11 out of 15. He required one-person assistance with transfers, bathing and toileting. 2. Record reviewThe 5/29/24 care plan documented Resident #11 exhibited cognitive loss related to altered cognitive performance and dementia. Interventions included discussion of concerns regarding overall status and health with the resident's family as needed, explaining all care before providing it to reduce resident tension and promote a comfortable experience, inviting and escorting to activity programs as desired, and reducing noise and distractions as indicated to provide a calm environment. The care plan also documented that Resident #11 was at risk for mood and behavior changes due to his mental diagnoses; he had a history of refusing care, verbal agitation, aggression, and racial comments towards the staff during care. Interventions included follow-up by for psychiatry services, observation for mental status and behavior changes when new medication started or with changes in dosage, providing time alone if he became physically aggressive, and encouraging the resident to communicate feelings.3. Resident interviewResident #11 was interviewed on 10/1/25, at 12:43 p.m. Resident #11 said Resident #3 threw water on his head a few months ago. Resident #11 said he notified the staff, but they did nothing. Resident #12 said sometimes Resident #3 spoke to him in an aggressive way.IV. Incident of physical abuse by Resident #3 towards Resident #12A. Resident #12 (victim)1. Resident statusResident #12, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, the diagnoses included cerebral atherosclerosis, sequelae of cerebral infarction, and generalized anxiety disorder. The 9/2/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. He required skilled occupational therapy due to impaired range of motion for transfers, toileting and bathing. 2. Record reviewThe 7/22/25 care plan documented Resident #12 had a psychosocial wellbeing problem related to anxiety, inability to problem solve, ineffective coping, and verbal aggression. Interventions included pain assessment, consultation with pastoral care, social services, and psychological services as needed, increased communication between resident, family, and caregivers about care, living, and environment, with explanations of all procedures, treatments, medications, and changes in conditions. Interventions also included checks every 15-minutes until determined by an interdisciplinary team (IDT), behavior monitoring, redirection through conversation around preferred activities, including smoking and golf, and when conflict arises, remove the resident to a calm, safe environment and allow him to share his feelings.3. Resident interviewResident #12 was interviewed on 10/1/25, at 10:40 a.m. Resident #12 said a few months ago, Resident #3 came to his room with a note. Resident #12 said the note said Resident #3 would come to Resident #12's bedroom and would cut his penis while he sleeps. Resident #12 said he should not be threatened like that. Resident #12 said he did report it to the staff, but he did not hear back from them. He said he knew they would not do anything about it. Resident #12 was interviewed again on 10/1/25, at 4 p.m. Resident #12 said he knew Resident #3 was schizophrenic, but he never saw her hitting anybody else. Resident #12 said Resident #3 threatened others, but just verbally or with notes that she left in their bedrooms. He also said Resident #3 went several times to the men's bedrooms, and he was afraid of her coming to this bedroom.V. Incident of verbal abuse between Resident #12 towards Resident #10A. Resident #10 (victim)1. Resident statusResident #10, age [AGE], was admitted on [DATE]. According to the September 2025 CPO, the diagnoses included type 2 diabetes mellitus, diabetic polyneuropathy, chronic obstructive pulmonary disease (COPD), severe major depressive disorder without psychotic disturbance, post-traumatic stress disorder (PTSD), and cognitive communication deficit. The 7/9/25 MDS assessment revealed the resident was cognitively intact with a BISM score of 14 out of 15. He required one person assistance with transfers, set up assistance with hygiene, and he is independent with toileting. 1. Observations On 9/30/25, at 1:58 p.m., Resident #10 was by the nurse's station, speaking loudly. At that moment, Resident #12 yelled at Resident #10 with racial and discriminatory insults, and bad words. Resident #10 yelled back to Resident #12 using similar language. The incident was witnessed by staff members, residents, and surveyors. 2. Record reviewThe 9/30/25 social service progress note documented Resident #10 talked very loudly in the hallway, and the other resident came out of his room yelling for this resident to be quiet because he could not hear his television This resident continued to argue with Resident #10. Both residents were redirected to their rooms; no injuries were noted. The police were notified The 1/15/25 care plan documented Resident #10 was at risk for decreased psychosocial well-being and adjustment issues, emotional distress, ineffective coping skills, behavioral symptoms, poor impulse control, adverse effects on function, mental, physical, social, or spiritual well-being related to his diagnosis of depression and suicidal thoughts. Resident #10 had a loud voice, which may be perceived by others as yelling. Resident #10 was also at risk for verbal altercations with others due to this. The resident often related this to being from New York and said he was not willing to change the tone of voice as he was just being himself. Interventions included: assessment of coping strategies and respect for the resident's wishes to the extent possible, assessment of preferences and choices with activities and encouraging involvement, establish rapport using therapeutic communication, encourage to voice feelings and frustrations as indicated, observe for tearfulness, increased agitation, and decreased participation in care, observe and document changes in behavior, including frequency of occurrence and potential triggers, and document and record behavioral episodes.The care plan documented, due to his PTSD, Resident #3 had a habit of talking extremely loud which is sometimes disturbing to others as it appears he was angry, but was only loud. Interventions included: administration of medication as ordered and monitoring for side effects (notify physician if observed); assisting to normalize feelings, so the resident knew he was not alone in his thoughts, experiences, feelings, and behaviors; attempting non-pharmacological approaches as indicated to reduce fears and/or anxiety related to incidents (music therapy, breathing exercise, talking to the resident about their feelings, providing a secure and comfortable environment, meditation, aroma therapy, reading materials, and offering preferred activities; contacting resident's representative or friend for comfort and support; and behavioral and psychological services as indicated, care in pairs for this resident related to his false accusations and made up stories about others (initiated on 9/30/25).3. Resident interviewResident #10 was interviewed on 10/2/25 at 11:10 a.m. Resident #10 said that due to his PTSD, he heard noises and had flashbacks when he had arguments. Resident #10 admitted he did not get along with Resident #12, and they had previous arguments, but it did not happen very often. Resident #10 said Resident #12 was the one who usually started the arguments and spoke badly about his home country, so he had to respond because it was personal for him.VI. Staff interviewsCertified nurse aide (CNA) #1 was interviewed on 10/1/25 at 11:15 a.m, CNA #1 said the staff tried to redirect Resident #3 to avoid or separate her from other residents, and report behaviors. However, CNA #1 said she did not hear about physical abuse cases with other residents. CNA #1 said the staff told Resident #10 several times he was too loud, and other residents got mad because of it. Registered nurse (RN) #3 was interviewed on 9/30/25 at 4:18 p.m. RN #3 said she was aware of the incident between Resident #2 and Resident #3. RN #3 said that most of the time, both residents had arguments, but with no physical aggression. RN #3 also said one of the problems was that Resident #3 refused to take her medication; and in order to prevent incidents, the staff did 15-minute checks when things got worse, took them to smoke at a different time, and had someone check on them. RN #3 said these interventions partially work because they both had issues with other residents. RN #3 said that she was not sure if Resident #3 had hit Resident #11 in the past because she was a relatively new employee.RN #3 said regarding the incident between Resident #10 and Resident #12, Resident #10 was really loud and Resident #12 told him to shut his mouth. RN #3 said and the argument started with personal insults. RN #3 said she saw something like this in the past.RN #3 said Resident #10 insulted several people, and was always loud, and he got mad if a staff member tried to redirect him.Licensed practical nurse (LPN) #3 was interviewed on 10/1/25 at 1:04 p.m. LPN #3 said she was aware of the incident between Resident #2 and Resident #3. LPN # 3 said after the incident, the staff separated them, reported to the abuse coordinator, interviewed the residents to find out what happened and how they felt, and started 15-minute checks.The social services director (SSD) was interviewed on 10/1/25 at 4:25 p.m. The SSD said Resident #3 refused medication and treatment, could get loud, and talked about men in a negative way. The SSD said Resident #3 was referred to psychiatric services.The DON was interviewed on 9/30/25 at 2:04 p.m. She said she was responsible for NHA duties in the absence of NHA and she was an abuse coordinator in the building at the moment. She said she was aware of Resident #3 passing notes to residents and staff with threatening messages. She said the notes were part of Resident #3's behavior. She said Resident #3 was not dangerous and her notes were disregarded since they were not a danger to other residents. The NHA said the facility did not investigate every note Resident #3 wrote.

Based on observations, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#7) of five residents reviewed for quality of care out of 12 sample residents. Specifically, the facility failed to change a wound care dressing daily for Resident #7, per the physician's order.Findings include:I. Resident #7A. Resident statusResident #7, age less than 65, was admitted on [DATE]. According to the October 2025 computerized physician orders (CPO), diagnoses included vascular dementia (cognitive decline due to damaged blood vessels to the brain), type 2 diabetes , diabetic neuropathy (damaged nerves due to diabetes), atrial fibrillation (abnormal heart rhythm) and hemiplegia (paralysis of one side of the body) following a stroke (brain cell death due to interrupted blood flow to the brain).The 8/4/25 minimum data set (MDS) assessment identified Resident #7 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented Resident #7 required substantial/maximal assistance from staff for toileting hygiene, dressing, and transfers and showering. B. Resident interview and observationResident #7 was interviewed on 10/1/25 at 11:50 a.m. Resident #7 said the nursing staff did not change her wound dressing. The resident pointed to a wound dressing on her left calf. Her left calf was wrapped in kerlix gauze and had tape on top of the gauze, which was dated 9/28/25 with a smiley face on it. C. Wound care observationsOn 10/1/25 at 1:40 p.m. the assistant director of nursing (ADON) and licensed practical nurse (LPN) #2 changed Resident #7's dressing. They washed their hands prior to putting gloves on. Resident #7's left middle calf still had the kerlix gauze wrapped around the calf with tape on top of the gauze dated 9/28/25 and signed with a smiley face, indicating the dressing was last changed on 9/28/25. The ADON removed the old dressing from the resident's wound. The resident's calf wound had a general red appearance and had some beefy red open areas, approximately quarter-sized with well defined borders. There were a few other quarter-sized scabbed areas LPN #2 said the resident's wound was overall healing. LPN #2 sprayed wound cleanser on the wound and patted it dry. She added calcium alginate (wound treatment), an abdominal pad (ABD - a large thick padded dressing) pad, wrapped the resident's calf with kerlix gauze and dated and signed the new dressing with a smiley face on top.D. Record review Review of Resident #7's October 2025 CPO revealed the following physician's order: For venous wound on left shin - clean with wound cleanser (a solution to remove contaminants) and pat dry, add calcium alginate (an antimicrobial, moist-healing wound dressing) and ABD to the wound, wrap with kerlix gauze every day shift, ordered 9/18/25 at 6:00 a.m.-However, observations on 10/1/25 revealed Resident #7's left calf dressing had not been changed since 9/28/25, three days prior (see observation above).II. Staff interviews Wound care physician (WCP) #1 was interviewed on 10/1/25 at 1:55 p.m. WCP #1 said Resident #7 had a venous ulcer due to her chronic conditions, including a lack of circulation to her legs, a lack of mobility and her increased age. WCP #1 said the current wound care order for Resident #7's calf wound was to change the left calf dressing daily. WCP #1 said she expected the nursing staff to change the wound dressing daily if she or the wound care nurse were not at the facility to change the dressing.The director of nursing (DON) was interviewed on 10/1/25 at approximately 3:30 p.m. The DON said she did not know why Resident #7's left calf dressing was not changed as scheduled. She said the nursing staff should follow the physician's wound care orders.

Based on record review and interviews, the facility failed to ensure a surety bond or otherwise provide assurance satisfactory to the secretary to assure the security of all personal funds of residents deposited with the facility. Specifically the facility failed to ensure the surety bond had the correct amount to cover the entire balance for the residents' personal needs account at the facility. Findings include: I. Facility policy and procedure The Management of Residents' Personal Funds policy, revised April 2017, was provided by the regional clinical resource (RCR) on 11/21/24 at 3:57 p.m. It read in pertinent part, Should the facility manage the resident's funds, the facility will act as a fiduciary of the resident funds and hold, safeguard, manage and account for the personal funds of the resident. Such funds will be managed in accordance with established policies outlined in this chapter that relate to financial management. II. Record review The surety bond letter was provided by the business office manager (BOM) on 11/20/24 at 3:00 p.m. It was dated 5/8/24 and signed by the facility's principal representative and the surety representative attorney-in-fact and documented the surety bond #30220042 patient funds were for the amount of $14,000.00. The certificate was effective 9/1/2023 at 12:01 a.m. and shall continue in full force and effect until 9/1/24, unless renewed by continuation certificate. The facility statements for resident personal funds were provided by the BOM on 11/21/24 at 1:00 p.m. and revealed the account balance was greater than $14,000.00 on multiple occasions in May 2024, June 2024, July 2024, August 2024, September 2024 and October 2024. III. Staff interviews The business office manager (BOM) was interviewed on 11/21/24 at 9:18 a.m. The BOM said the amount of coverage for the surety bond was increased on 11/20/24 to $50,000.00 (during the survey). The BOM said the bonding company had added the $50,000.00 coverage retroactive to 10/1/24. The BOM said the facility recognized on 11/20/24 (during the survey) the need to increase the personal funds coverage because the balance totals had been greater than $14,000.00 at times over the past several months. The BOM said he was told by the facility's corporate business office that the facility had surety bond coverage for September 2024. -However, the BOM said the letter did not provide coverage retroactive to 9/1/24, the ending date of previous coverage. The nursing home administrator (NHA) was interviewed on 11/21/24 at 1:41 p.m. The NHA said the facility should have had a surety bond which covered the total balance in resident personal funds at all times. IV. Facility follow up The BOM provided an updated surety bond on 11/21/24 at 1:00 p.m. (during the survey). The BOM provided a document titled Bond Increase Rider which increased the #30220042 bond from $14,000.00 to $50,000.00 effective 9/1/24. The rider was signed on 11/20/24 by a facility principal representative and the surety company attorney-in-fact.

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to provide a response, action and rationale for food concerns brought up in the resident council meetings. Findings include: I. Facility policy and procedure The grievances and complaints filing policy, revised April 2017, was provided by the nursing home administrator (NHA) on 11/21/24 at 3:32 p.m. It revealed in pertinent part, All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. II. Resident group interview A group interview was conducted on 11/19/24 at 1:01 p.m. with five residents (Resident #10, #12, #21, #46 and #68) who were identified as alert and oriented through facility and assessment. Resident #10 said he wanted different snacks than half of a ham sandwich. He said he was told this was what the facility offered as snacks. Resident #12 said she bought her own snacks because she did not like the snacks offered by the facility. Resident #21 said he did not like the snacks offered by the facility. Resident #21 said when he had bagels brought in by a resident representative an unknown nurse would not reheat the bagel. Resident #21 said he was trying to elevate his snacks because he did not like the facility's snacks. The residents said they did not feel the facility provided prompt resolutions to their concerns. III. Resident council notes The June 2024 resident council notes were reviewed. It revealed residents wanted infused water and the residents said the food was occasionally too spicy. The residents wanted fresh snacks and did not want as many processed foods. The residents asked to cook on the barbeque grills and wanted more slow cook methods like cooking and smoking for more tender meats. The 7/23/24 resident council notes were reviewed. -There was no documentation on the 7/23/24 resident council notes that the concerns the residents brought up in the June 2024 resident council meeting were reviewed or approved by the residents. The 10/21/24 resident council notes were reviewed. The residents asked for more protein at breakfast and said the eggs were not good. The residents asked for more fresh fruit, asked for sliced oranges and wanted easy to peel oranges like cuties. The residents also said the portion sizes were small and they felt hungry. The 11/18/24 resident council notes were reviewed. -There was no documentation on the 11/18/24 resident council notes that the concerns the resident brought up in the October 2024 resident council meeting were reviewed or approved by the residents. V. Staff interview The NHA was interviewed on 11/21/24 at 9:50 a.m. The NHA said the activities director (AD) was the interim AD and was hired on 8/5/24. The NHA said the AD had a consultant to monitor and support the AD. The NHA said the consultant started on 8/12/24. The NHA said the AD was responsible for coordinating the resident council meeting. The NHA said the resident council agenda was driven by the residents. The NHA said the agenda covered old topics and new business. The NHA said the residents knew when the resident council occurred because they had an activities calendar in their room. The NHA said when a resident brought up a concern at resident council, the AD told the department either verbally or through a text message. The NHA said he assumed the AD followed up with the department. The NHA said the AD asked the resident if they needed help to fill out a grievance form or if the resident wanted the AD to fill out the grievance form. The NHA said he did not know the AD did not go over concerns with the resident council to ensure the residents approved of the resolution. The NHA said there was no documentation that the staff responded to the residents' concerns for the June 2024 or October 2024 resident council. The NHA was interviewed on 11/21/24 at 3:45 p.m. The NHA said a performance improvement project (PIP) for activity services was identified on 10/30/24. VI. Facility follow up The NHA provided the activity services PIP on 11/22/24 at 11:50 a.m. It revealed the PIP addressed the facilities activities program. The PIP was identified on 10/30/24. The facility was in the process of reconfiguring the activity program to better meet the residents' needs. The activity changes included weekend activities, residents directed activities and one on one activities. -However, the PIP did not address how the facility would provide a response, action and rationale for concerns discussed at resident council.

Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable and attractive. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include: I. Resident interviews Resident #13 was interviewed on 11/18/24 at 1:31 p.m. He said the food was served cold. He said cold eggs were terrible. Resident #9 was interviewed on 11/18/24 2:21 p.m. She said the food was terrible and not nutritious. She said the food was served cold. She said the facility served what they like and not what she likes. Resident #39 was interviewed on 11/18/24 at 2:40 p.m. She said the food was terrible, because the food was either undercooked and raw or overcooked. Resident #29 was interviewed on 11/18/24 at 2:52 p.m. He said the texture of the food was terrible. He said it was hard to cut the food. He said once the food was chopped it was hard to chew. He said the meat was the hardest to chew but most of the food was hard to chop and chew. Resident #68 was interviewed on 11/18/24 at 4:05 p.m. He said the food was not good and was not fresh. He said he ordered from a food delivery service to replace the food the facility provided to him. II. Record review The June 2024 resident council meeting notes were reviewed. It revealed the food was sometimes too spicy. The residents said there were too many processed foods. -There was no documentation of what the facility did to resolve the grievance. The October 2024 resident council meeting notes were reviewed. It revealed a resident said the eggs were not good. -There was no documentation of what the facility did to resolve the grievance. IV. Observations A test tray for a regular diet was evaluated by four surveyors immediately after the last resident had been served their meal for lunch on 11/21/24 at 12:18 p.m. The test tray consisted of cheese pizza, tossed salad with ranch dressing, a dinner roll and peaches. -The cheese pizza was dry, crunchy and tasted bland. The pizza was difficult to cut. -The tossed salad consisted of leafy greens. No other vegetables were on the salad. III. Staff interviews The dietary manager (DM) and the corporate dietary director (CDD) were interviewed together on 11/21/24 at 2:36 p.m. The CDD said pizza should not be crunchy and hard to eat. The CDD said she would revisit having pizza on the menu because residents either loved or disliked pizza. The DM said CK #1 had a difficult time slicing the pizza during meal service because the crust was hard. The DM said the salad should have had cucumber as a garnish. The DM said the pork chop was seasoned with garlic, spices, and salt. The DM said the pork chop was baked in the oven and then stored in hot water in a metal tin during meal service. The CDD said the pork chop was stored in hot water to prevent the meat from drying out. The DM and the CDD said they did not know residents said the meat was hard to slice. The nursing home administrator (NHA) was interviewed on 11/21/24 at 3:45 p.m. The NHA did not know the residents did not like the taste of the food. The NHA said a performance improvement project (PIP) for dietary services was implemented on 11/1/24. The NHA said the PIP did not include the palatability of the food. The NHA said a food satisfaction survey was completed for each resident. VI. Facility follow up The NHA provided the dietary services PIP on 11/22/24 at 11:50 a.m. It revealed the PIP addressed a food satisfaction survey was completed on 11/1/24. The survey asked residents if the resident liked snack options, how to order alternative meal options, meal portion sizes and meal choices. -The survey did not include if the residents liked the taste, texture, and consistency of food served during meals.

Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for two (#60 and #63) of three residents out of 35 sample residents. Specifically, the facility failed to: -Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #60 and Resident #63 understood the agreement before signing the arbitration agreement; and, -Ensure staff reviewing the arbitration agreement with Resident #60 and Resident #63 had knowledge and skills to assess cognitive ability of residents to ensure residents understood the components of the agreement at the time it was presented to them. Findings include: I. Facility policy and procedure The Binding Arbitration Agreements policy, revised November 2023, was provided by the nursing home administrator (NHA) on 11/20/24. It read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about important aspects of their health, welfare and safety. Upon admission, or any time during the resident's stay, the resident (or representative) may be presented with the opportunity to utilize a binding arbitration agreement to resolve disputes as long as the terms and conditions of the agreement comply with federal regulations. Binding arbitration agreements may be offered either before (pre-dispute) or after (post-dispute) a dispute arises. Binding arbitration agreements are voluntary for the residents. Residents are not compelled, pressured, or coerced to enter into a binding arbitration agreement. It is unambiguously communicated to residents (or representatives) that binding arbitration agreements are optional and not required as a condition of admission or to receive care at this facility. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding (litigation). The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manner that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement. Any facility personnel who are responsible for explaining the terms and conditions of binding arbitration agreements to the residents (or representatives) are trained in the specifics of this policy. II. Resident #60 A. Resident status Resident #60, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included chronic respiratory failure, diabetes and altered mental status. The 9/4/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. B. Resident interview Resident #60 was interviewed on 11/20/24 at 2:14 p.m. He said he understood what the arbitration agreement was and was able to summarize the main points of the agreement. -However, he said he did not recall signing it with this facility. He said when he was admitted to the facility, he was in a haze, and I did not remember anything. C. Record review and additional resident interview Review of the admission records revealed Resident #60 signed binding arbitration agreement on 9/1/23 in the presence of marketing coordinator (MC). The resident #60 requested a copy of the arbitration agreement. The signed copy of the binding arbitration agreement was provided to the resident in the presence of NHA on 11/20/24 at 3:35 p.m. The resident reviewed the document and stated: this is not my signature, I did not sign this. III. Resident #63 A. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included frontotemporal neurocognitive disorder (progressive brain disease), bipolar disorder (mental disorder that causes unusual behavior shifts), major depressive disorder and anxiety disorder. The 10/8/24 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 10 out of 15. B. Resident interview Resident #63 was interviewed on 11/20/24 at 2:25 p.m. He said he did not know what a binding arbitration agreement was. He said he did not recall signing such an agreement. C. Record review Review of the admission records revealed Resident #63 signed a binding arbitration agreement on 10/3/24 in the presence of MC. IV. Staff interviews The MC was interviewed on 11/20/24 at 1:14 p.m. The MC said he was the marketing coordinator and part of his responsibilities was to go over the admission package that included arbitration agreement. The MC said the arbitration agreement was presented at the same time as the admission packet. He said he explained the details of the agreement to the residents before they signed it. He said the residents could rescind the agreement within 30 days of signing, by telling him so. The MC said there was no formal process to document the process. The NHA was interviewed on 11/21/24 at 10:43 a.m. The NHA said Resident #60 did say he was in a haze when he signed the document. He said he contacted his legal team for advice and since Resident #60 was cognitively intact per the BIMS assessment, the agreement was valid. The MC was interviewed a second time on 11/21/24 at 2:30 p.m. The MNC said he did not recall the time or any details of the events when he witnessed Resident #60 and Resident #63 signing the binding arbitration agreement. He said his background was in business and marketing. He said he did not have a nursing/medical or clinical background. He said he assumed residents understood the legal terminology if they did not ask any questions. Primary care provider (PCP) #1 was interviewed on 11/21/24 at 1:27 p.m. PCP #1 said she was the physician for Resident #60 and Resident #63. She said there were different levels of cognition. She said being able to make decisions about daily routine was a different type of cognition than understanding legal terminology. She said even individuals with good cognition might not fully understand legal terminology. She said when the residents admitted they could be under the influence of medications and have limited judgement. She said for an individual who was not a clinical medical professional it would be difficult to determine if the resident had the full mental capacity to make a legal decision at a certain time. PCP #1 said when Resident #60 was admitted , he was under the influence of medications and could not recall all the events that occurred to him in the hospital and after. She said she had several conversations with him where she went over his medical situation and treatments he received in the hospital. She said Resident #60's cognition was improving, but it was not at its full capacity when he was admitted . PCP #1 said Resident #63 had a neurocognitive disorder that damaged nerve cells in the frontal and temporal lobes of his brain. She said it would take a clinical medical professional to determine Resident #60's cognitive capacity to understand the legal terminology at the time it was offered to him.

Based on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for two (#4 and #60) of two out of 35 sample residents. Specifically, the facility failed to appropriately assess Resident #4 and Resident #60 for self-administration of medications. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 2016, was retrieved on 11/27/24, Do not leave medications at the bedside. If you leave the medication on the bedside table, how do you know they took the medication? Someone else could come in and take or discard the medication. II. Facility policy and procedure The Storage of Medications policy, updated November 2020, was provided by the director of nursing (DON) on 11/21/24 at 3:57 p.m. It read in pertinent part, Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. III. Resident #4 A. Resident status Resident #4, age greater than age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included sepsis, asthma, chronic heart failure, lymphedema (fluid retention), chronic kidney disease, hypertension (high blood pressure), cognitive communication deficit, and stage four pressure ulcer of sacral region. The 8/20/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. According to the assessment, the resident needed setup or clean up assistance with eating, oral hygiene and showering. B. Observations and record review On 11/18/24 at 11:03 a.m., during an interview with Resident #4, a tube of three percent lidocaine was found on the resident's bedside table. On 11/20/24 at 9:13 a.m., during a follow-up interview with Resident #4, a tube of three percent lidocaine was found on the resident's bedside table and a tube of five percent lidocaine was located in a rack a few feet away from the resident's bed. -Review of the November 2024 CPO did not reveal physician's orders for either of the tubes of lidocaine for Resident #4. -There were no assessments completed that indicated the resident was able to self administer medications. -The care plan, updated 11/12/24, did not reveal the resident wanted to self administer medications. IV. Resident #60 A. Resident status Resident #60, age greater than age 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included chronic respiratory failure, type two diabetes mellitus, gastro esophageal reflux disease, hypotension (low blood pressure), and altered mental status. The 9/4/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. According to the assessment, the resident was dependent on staff for showers, lower body dressing and personal hygiene. The resident was able to eat independently. B. Observations and record review On 11/20/24 at 7:50 a.m., during observation of medication pass with licensed practical nurse (LPN) #2, the following medications were left on the Resident #60's bedside table: Vitamin C, Tums (used to treat heartburn and indigestion), Glimepiride (used to treat high blood sugar), Ocuvite (a vitamin for eye health), and Protonix (used to treat excessive stomach acid causing heartburn). -A review of the November 2024 CPO revealed there were no physician's orders for self administration of medication. -There were no assessments completed that indicated the resident was able to self administer medications. -The care plan, updated 10/31/24, did not reveal the resident wanted to self administer medications. V. Staff interviews The director of nursing (DON) was interviewed on 11/20/24 at 9:14 a.m. The DON said she did not assess or allow any residents in the facility to self administer medications. She said it was important for the nursing staff to observe the residents as they took their medications to ensure the medications were taken correctly and on time. The DON said there were not any residents in the facility that were permitted to keep any medications or topical treatments at their bedside. Registered nurse (RN) #1 was interviewed on 11/21/24 at 10:48 a.m. RN #1 said medications should not ever be left at the bedside. She said there were not any residents in the facility that were permitted to self administer their medications. RN #1 said medications that were left at the beside could be used incorrectly by the resident, get thrown away and not taken at all, hoarded and taken all at once causing an overdose or other residents could take the medications that were not prescribed for them.

Based on record review and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) Level II determination and evaluation report into the assessment, care planning and transition of care for one (#63) of three residents out of 35 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in Resident #63's PASRR Level II report; and, -Ensure the PASRR Level II recommendations were included in Resident #63's care plan. Findings include: I. Facility policy and procedure The Behavioral Assessment, Intervention and Monitoring policy, revised March 2019, was provided by the nursing home administrator (NHA) on 11/20/24 at 4:00 p.m. It read in pertinent part, The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The care plan will incorporate findings from the comprehensive assessment and PASARR Level II determinations (as appropriate), and be consistent with current standards of practice. II. Resident status Resident #63, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included renal insufficiency, dementia, anxiety disorder, depression, and bipolar disorder (mental illness that causes unusual shifts in behavior). The 10/8/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview of mental status (BIMS) score of ten out of 15. The assessment indicated the resident required setup assistance with oral hygiene and personal hygiene. The assessment indicated the resident had been evaluated for a PASRR Level II and had recommendations (see record review below). III. Record review A review of the Resident #63's PASRR Level II, dated 9/14/24, revealed the resident had depression, anxiety and behaviors. The PASRR Level II documented the services were to be provided by a qualified community mental health professional such as individual therapy. The facility was to offer psychotherapy to Resident #63, per his recent neuropsychological report, to monitor symptoms and to provide support for him and facility staff in dealing with depression and behaviors. -A review of the comprehensive care plan, dated revised 10/14/24, did not reveal the resident's PASRR Level II screening and specialized services recommendations for his mental illness. -A review of Resident #63's electronic medical record (EMR) did not reveal documentation that indicated services were requested or established recommended on the Level II PASRR. -A review of the November 2024 CPO did not reveal a physician's order for the resident to be seen for psychotherapy. However, it did reveal orders for an antidepressant, antipsychotic and antianxiety medications. IV. Staff interviews Social services director (SSD) #1 was interviewed on 11/20/24 at 12:42 p.m. SSD #1 said the PASRR Level II recommendations were not followed up on according to her review of Resident #63's EMR. She said the reason the facility did not identify that Resident #63 was not receiving the care and services that were recommended in the Level II PASRR was because the facility did not do a whole house audit to identify which resident's had Level II PASRR recommendations until today (11/20/24). She said she was in the process of auditing all residents' PASRRs to ensure all recommendations were followed and maintained a spreadsheet to track those with PASRRs Level II recommendations and if the residents were receiving therapy, were offered therapy or had refused. SSD #1 said she believed the social services department had a lot of holes in the program and she had been working to identify gaps and make the process more seamless. She said she had been working in the facility for one month. The director of nursing (DON) was interviewed on 11/21/24 at 10:10 a.m. The DON said the recommendations from the PASRR Level II were maintained by the SSD. She said they had recently lost the SSD and hired a new SSD about a month ago. She was not sure where the current SSD was in the process of identifying or obtaining services for residents with recommendations.

Based on observations, record review and interviews, the facility failed to ensure one (#278) of three residents reviewed for activities out of 35 sample residents received individualized activities in accordance with standards of care. Specifically, the facility failed to provide person centered comforting activities for Resident #278 who was at end of life. Findings include: I. Facility policy and procedure The Safe and Homelike Environment policy, revised August 2024, was provided by the regional clinical resource (RCR) on 11/21/24 at 3:57 p.m. It read in pertinent part, The facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. A homelike environment is one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include the resident's opinion of the living environment. The Activity Programs policy, revised June 2018, was provided by the RCR on 11/21/24 at 3:57 p.m. It read in pertinent part, Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Adequate space and equipment are provided to ensure that needed services identified in the resident's plan of care are met. II. Resident #278 A. Resident status Resident #278, age 75, was admitted on [DATE] and passed away at the facility on 11/21/24 According to the November 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, malnutrition and dementia with agitation. The 11/12/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of zero out of 15. Resident #278 was dependent on staff for activities of daily living (ADLs). The MDS assessment revealed it was very important for Resident #278 to listen to music she likes, be around animals such as pets and keep up with the news. B. Record review Resident #278's activity care plan, initiated 11/20/24, included inviting the resident's family members to attend activities with the resident to encourage resident participation. -The care plan did not reveal any of the resident's identified preferences or how to implement them with the resident current status. C. Observations On 11/18/24 at 2:00 p.m. Resident #278 was lying in bed with a hospital gown on. There was no decor or personal belongings in her room and the room was quiet. On 11/19/24 at 11:26 a.m., Resident #278 was in bed sleeping with a hospital gown on. The room was quiet and there were no personal belongings identified other than a small stuffed animal next to the resident. There was a foul odor in the room. On 11/19/24 at 1:09 p.m Resident #278 was lying in bed with her eyes closed. There were no personal belongings in the resident's room. D. Resident representative Resident #278's representative was interviewed on 11/19/24 at 11:24 a.m. The representative said the resident was receiving hospice care and required comfort care measures. E. Staff interviews Certified nurse aide (CNA) #2 was interviewed on 11/19/24 at 2:45 p.m. CNA #2 said she did not know if Resident #278 would respond to music or television. She said the staff had not tried to play music for the resident. CNA #2 said the resident often yelled and cried. Licensed practical nurse (LPN) #4 was interviewed on 11/19/24 at 2:50 p.m. LPN #4 said Resident #278 was receiving comfort care. LPN #4 said Resident #278's room was not personalized and he would not want to stay in the room if he were a resident. LPN #4 said he did not know if anyone had tried to play music for the resident and he did not know Resident #278's activity preferences. The activities director (AD) was interviewed on 11/19/24 at 2:58 p.m. The AD said Resident #278 was not willing to be interviewed when the AD initially attempted, but was able to determine the resident's preferences by 11/12/24. The AD said she did not have supplies to play music for the residents and did not know if the televisions in resident rooms had this capability. The director of nursing (DON) and the RCR were interviewed on 11/19/24 at 4:00 p.m. The DON said Resident #278's room was dull and there were very few items in the room to make it personalized. The DON said the facility had equipment available to play music. The RCR said the expectation at the facility was that anyone could initiate care that was identified by resident preferences as very important to the resident. The RCR said the AD should communicate to the rest of the nursing staff if an assessment was completed. The RCR said the facility team was going to evaluate all resident rooms to ensure other rooms had an appropriate environment. The hospice nurse (RNH) was interviewed on 11/20/24 at 12:54 p.m. The RNH said if Resident #278 had indicated music was important to her, she would expect staff to implement this. The RNH said there could be a change in resident preferences and it was important to continue to assess this. The AD was interviewed again on 11/20/24 at 4:18 p.m. The AD said she had not had training regarding the needs and preferences of residents who received hospice care. She said she read about the needs of hospice residents on 11/20/24 and implemented a more homelike atmosphere on the morning of 11/20/24 (during the survey). The AD said she provided a blanket, music and aromatherapy. The AD said the resident preferences were identified on 11/12/24 but the preferences had not been added to the care plan or provided to the resident.

Based on observations, record review and interviews, the facility failed to ensure one (#39) of three residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion out of 35 sample residents. Specifically, the facility failed to establish a consistent restorative nursing program within the facility to ensure Resident #39 did not have a potential decline in activities of daily living (ADL). Findings include: I. Facility policy and procedure The Restorative Nursing Services policy, revised July 2017, was provided by the director of nursing (DON) on 11/21/24 at 3:57 p.m. It read in pertinent part, Restorative nursing care consists of nursing intervention that may or may not be accompanied by formalized rehabilitative services (physical, occupational or speech therapies). Restorative goals and objectives are individualized, resident-centered, and are outlined in the resident's plan of care. Restorative goals may include, but are not limited to supporting and assisting the resident in: -Adjusting or adapting to changing abilities; -Developing, maintaining or strengthening his/her physiological and psychological resources; -Maintaining his/her dignity, independence and self-esteem; and, -Participating in the development and implementation of his/her plan of care. II. Resident #39 A. Resident status Resident #39, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physicians orders (CPO), the diagnoses included heart disease, chronic respiratory failure and muscle weakness. The 9/7/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 14 out of 15. She had no behaviors and did not reject care. According to the MDS assessment, the resident did not receive restorative nursing services. B. Resident interview Resident #39 was interviewed on 9/26/22 at 11:23 a.m. Resident #39 said she was supposed to get ROM therapy every day but that did not happen. She said she felt like she was getting weaker and losing strength. C. Record review A review of the November 2024 CPO revealed the following physician's orders: -Restorative nursing to perform ROM to bilateral lower extremities daily, ordered on 10/4/23. A review of the task sheet for restorative nurse assistant (RNA) services for the past 30 days revealed the following: -Resident #39 received RNA services on 11/15/24, 11/16/24, 11/17/24, 11/18/24, 11/19/24 and 11/20/24 for a total of six days out of 30 days. D. Staff interviews The physical therapist (PT) was interviewed on 11/21/24 at 9:06 a.m. The PT said the facility has not had a restorative nursing program since October 2024. He said he recently put a book together for the certified nurse aides (CNA) with instructions on how to use splints for residents with contractures. PT said the CNA's were able to perform range of motion exercises with residents if they had time. The nursing home administrator (NHA) was interviewed on 11/21/24 at 9:51 a.m. The NHA said there was a restorative nursing program at the facility and it was the responsibility of the DON to oversee it. He said the floor staff were all trained to perform restorative nursing therapy. The therapy consultant (TC) was interviewed on 11/21/24 at 12:36 p.m. The TC said the facility did not have a restorative nursing program and he was asked to help them establish one in November 2024. He said he trained one staff member so that person would be able to train the rest of the CNA staff. CNA #3 was interviewed on 11/21/24 at 1:00 p.m. CNA #3 said she was trained by the PT on 11/18/24 (during the survey) on how to complete restorative services. She said the facility started the restorative program the week prior to the survey start. The staffing coordinator (SC) was interviewed on 11/21/24 at 1:17 p.m. The SC said she was trained by the TC on 11/13/24. She said the TC taught her how to train the CNA staff to perform restorative nursing exercises. The SC said she has trained about 75% of the staff so far.

Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents out of three sample residents reviewed for discharge planning. Specifically, the facility failed to: -Provide an appropriate discharge process for Resident #3; and, -Notify the family that Resident #3 was transferred to another skilled nursing facility until after the resident had already been transferred. Findings include: I. Facility policy and procedure The Discharge Summary and Plan policy, revised October 2022, was provided via email by the director of nursing (DON) on 10/14/24 at 11:33 a.m. It read in pertinent part, When a resident's discharge is anticipated, a discharge summary and post-discharge plan is developed to assist the resident with discharge. Policy Interpretation and Implementation The discharge summary includes a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. Discharge potential (the expectation of discharging the resident from the facility within the next three months. Every resident is evaluated for his or her discharge needs and has an individualized post-discharge plan. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and his or her family and includes: -Where the individual plans to reside; -Arrangements that have been made for follow-up care and services; -A description of the resident's stated discharge goals; -The degree of caregiver/support person availability, capacity and capability to perform required care; and, -How the IDT (interdisciplinary team) will support the resident or representative in the transition to post-discharge care. The resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan. The resident or representative (sponsor) is asked to provide the facility with a minimum of a seventy-two (72) hour notice of a discharge to assure that an adequate discharge evaluation and post-discharge plan can be developed. A member of the IDT reviews the final post-discharge plan with the resident and family at least twenty four (24) hours before the discharge is to take place. II. Resident #3 A. Resident status Resident #3, age 79, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included acute kidney failure, dementia without behavioral disturbances, type 2 diabetes mellitus, hypertension (high blood pressure), anemia, unsteadiness on feet and acute kidney failure. The 4/4/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He required partial to moderate assistance with showers, supervision with toileting, and was independent with oral hygiene and eating. He had an indwelling catheter, and was always incontinent with bowel. The assessment indicated the resident did not have any physical or verbal behaviors directed towards others. He did not reject care from staff. He did not wander and did not have a wander elopement guard. -However, record review and interviews indicated the resident did have a wander elopement guard (see below). B. Resident #3's family member interviews One of Resident #3's family members was interviewed on 10/10/24 at 1:48 p.m. The family member said all of the resident's family members were very involved with the care of Resident #3. She said Resident #3 was a gentle soul and did not have negative behaviors. The family member said he did wander throughout the facility looking for sunlight to sit in. The family member said a social worker approached another family member on Wednesday 5/29/24, in the afternoon, and asked if the family would consider transferring Resident #3 to a facility with a secured unit because the facility staff felt Resident #1 was exit seeking. The family member said the other family told the social worker that the family would consider transferring Resident #3 to another facility with the request that the family be allowed to tour a few secured facilities in order to choose which facility the family felt was best for their loved one. The family member said the conversation on 5/29/24 was the first time the facility staff had spoken with the family about possibly moving Resident #3. The family member said on Friday 5/31/24 in the afternoon, just 48 hours after the conversation about possibly transferring the resident to another facility, the family was informed Resident #3 had been transferred to a different facility. The family member said the family was shocked Resident #3 had been transferred and a family member left work to go to the facility to see what had happened. The family member said by the time the family member got there, Resident #3 was already gone. The family member said the other family member gathered Resident #3's belongings and headed to the new facility where Resident #3 had been transferred. Another family member of Resident #3 was interviewed on 10/15/24 at 3:00 p.m. The family member said the family was not afforded the privilege to look at places for Resident #3 before the facility moved him. The family member said the resident was a gentle soul and he believed the situation brought the family and the resident trauma. The family member said the new facility where Resident #3 was transferred was costing the family more money than the original facility cost. The family member said no one should live through what their family had gone through because of how Resident #3 had been transferred from the facility. C. Record review On 3/4/24 a family member signed a consent form for Resident #3 to have a wander guard placed. The comprehensive care plan, initiated 10/9/23, revealed Resident #3 was an elopement risk/wanderer, was disoriented to place, had a history of attempts to leave the facility unattended, had impaired safety awareness and wandered aimlessly. The resident had impaired cognitive function/dementia or impaired thought processes with dementia and wandered with no purpose. Pertinent interventions included a wander guard to alert staff to the resident's attempts to leave through the doors (initiated 5/23/24), one-to-one supervision at all times (initiated 5/24/24) and discussing concerns regarding the resident's overall status/health with the resident/family as needed (initiated 5/25/24). A 5/31/24 at 12:32 p.m. social services progress note revealed, the social service worker received an email from the receiving facility for Resident #3 that they were able to accept the resident. -However, according to family interviews (see above) and staff interviews (see below), the family was not notified until after the resident had already been transferred to the other facility. A 5/31/24 at 5:10 p.m. social service progress note revealed the former social service director (SSD), who was now one of the facility's social service assistants (SSA), left a voicemail for the family in regards to Resident #3's discharge. The progress note documented in pertinent part, (SSD) Apologized for how social services handled the discharge by not providing proper notice and the proper documentation support in the efforts of finding proper placement for (Resident #3). SSD stated that there will be reeducation and training regarding how SSA can better and appropriately handle future discharges. Furthermore, SSD outlined the reasons for discharge regarding safety concerns with wandering around the facility. SSD explained that the new facility will be safer for the resident and that they were able to accept him in a placement in (the same city). SSD accepted full responsibility of the actions of the social services team and will ensure the proper training and education is completed. -There was no further documentation in Resident #3's electronic medical record (EMR) regarding the resident's transfer to the new facility on 5/31/24. III. Staff interviews The DON and the corporate consultant (CC) were interviewed together on 10/14/24 at 12:15 p.m. The DON and the CC said Resident #3 was a sweet person who had a wander guard and often tried to wander out the door. Both the DON and the CC said the discharge for Resident #3 was not done correctly. The DON and the CC said the facility did not call the family, nor did they provide the family with other facility names to go and look at before the resident was discharged to a new facility. The DON and the CC said the facility cut the family out and did not tell the family about the place or let the family go visit the new place ahead of time. The DON and the CC said the facility had a breakdown in their process for discharge. The DON and the CC said since the incident happened to Resident #3, the facility management developed a better way to ensure individuals would be discharged properly. The DON and the CC said discharges were now discussed in morning meetings and, if there would be a discharge, everyone on the interdisciplinary team (IDT) team would be involved in the discharge planning. The SSA (who was the facility's former SSD) was interviewed on 10/15/24 at 1:00 p.m. The SSA said he was the SSD at the time of Resident #3's discharge. The SSA said he was not involved in the situation until the end of the day on 5/31/24. The SSA said the resident was exit seeking and did have a wander guard on for many months. The SSA said there was a lot of miscommunication between the former nursing home administrator (FNHA) and the family of Resident #3. The SSA said as soon as the FNHA got word the receiving facility approved the resident's transfer, the FNHA sent Resident #3 there immediately. The SSA said the family was not given notice nor was the family given any choices of places to visit for Resident #3. The SSA said the situation did not happen the way a discharge was supposed to happen. The SSA said the family was not called until late afternoon on 5/31/24, after Resident #3 had already been transferred to the new facility. The SSA said he did not write any discharge care plans or a discharge summary before or after Resident #3 was discharged .

Based on observations, interviews, and record review, the facility failed to provide an environment as free of accident hazards as possible and failed to ensure residents received adequate supervision and assistance devices to prevent accidents for nine (#1, #2, #3 #14, #15, #21, #33, #34 and #38) of 17 residents reviewed for accident hazards out of 38 sample residents. I. Facility failure to prevent elopement and implement a comprehensive and effective approach to prevent further elopement created a situation of immediate jeopardy for serious harm. Resident #1 and Resident #2 eloped from the facility together on 2/19/24 between 9:30 a.m. and 10:00 a.m. Both residents were assessed by the facility to be at risk for elopement and had orders to wear a wander-prevention device. The residents were found in a neighborhood two and a half blocks away from the facility when a good Samaritan called the police. Resident #1 had fallen and was transferred to the hospital with a broken hip. Resident #2 returned to the facility. She was not wearing a wander-prevention device as ordered. On 2/29/24, Resident #2 was observed. As on 2/19/24, and without facility knowledge, the resident was not wearing a wander-prevention device. Further observations revealed the front doors to the facility failed to alarm with the approach of a wander-prevention device and the door was open. The facility did not have a plan to monitor the doors 24 hours per day. Additionally, the facility failed to ensure that the wander-prevention devices worn by Resident #14, #15, and #21 were checked for function each shift, that Resident #3, assessed and care planned for a wander-prevention device, had orders for use of the device; and that the facility policy addressed the prevention of elopement. The facility's failure to prevent elopement and implement a systemic and effective approach to prevent further elopement created a situation of immediate jeopardy for serious harm. II. Facility failure to take steps to address other accident hazards. Observations, record review, and interview revealed the facility failed to: Timely complete smoking assessments; failed to provide assistive smoking devices; and failed to securely store chemicals and used razors. Findings include: ELOPEMENT I. Immediate jeopardy A. Findings of immediate jeopardy On 2/19/24 at approximately 10:00 a.m., two residents, Resident #1 and Resident #2, with known exit-seeking wandering behaviors, left the facility together without the facility's knowledge. Both residents had physician orders for the use of a wander-prevention device. The residents left the building through the front door of the facility which was equipped with a wander-prevention system but did not lock or alarm. Resident #1 and Resident #2 were found by the police on 2/19/24 at approximately 10:15 a.m. in a neighborhood two and a half blocks away from the facility. Resident #1 had fallen and sustained a fractured hip. Resident #2 returned to the facility. Record review revealed Resident #2 was not wearing a wander-prevention device on the day of the elopement as ordered or when observed during the survey on 2/29/24 at 12:34 p.m. Record review further revealed three of the residents with orders for wander-prevention devices (Resident#14, #15, and #21) had no ongoing monitoring to ensure their devices were functioning properly. The facility's response following Residents #1 and #2's' elopement through the front door was to have the receptionist monitor the area during the day. However, the facility did not have a plan to monitor the front door when there was not a receptionist on duty. Further, on 2/29/24 at 9:00 a.m., there was no receptionist observed for several minutes at the front entrance. Staff reported the doors were locked after 5:00 p.m. There were mixed reports on how the doors could be opened after 5:00 p.m. The facility had not implemented a comprehensive and effective process to ensure the front entrance was not left unsecured or unattended to prevent additional resident elopements. The facility was located in the proximity of heavy road traffic, making further serious harm or serious injury likely. Furthermore, the facility was not checking the function of all of the wander prevention devices routinely. B. Facility notice of immediate jeopardy On 2/29/2024 at 2:22 p.m., the nursing home administrator (NHA) was informed that the facility's failure to prevent elopement and implement a comprehensive and effective approach to prevent further resident elopement created a situation of immediate jeopardy for serious harm. C. Temporary plan to keep residents safe On 2/29/24 at 5:40 p.m., the NHA provided a temporary plan to keep residents safe from elopement. The plan included that Resident #2 was placed on one-to-one supervision with a staff member at all times, and a staff person would be at the front desk 24 hours per day, seven days per week until the front door functioned properly - locking and alarming when in a closed position with the approach of a wander-prevention device and alarmed if a resident with a wander-prevention device approached and the door was in the open position. Residents with wander-prevention devices would all be checked for function each shift. D. Facility plan to remove immediate jeopardy The Plan to remove immediate jeopardy read: Beginning on 2/29/24, the Elopement and wandering policy was reviewed/revised by the director of nursing (DON) or Designee to ensure the facility is following policy. The DON or designee educated staff beginning on 2/29/24 on the policy for Wandering, Elopement and Resident safety with a plan to complete 3/6/24. The DON or designee educated staff beginning 3/5/24 on a new Elopement prevention policy, with a plan to complete staff in-service on 3/6/24. Staff not educated, including agency staff, will be educated by the NHA or designee before their next shift. Resident #1 is discharged . Resident #2 was discharged from the facility and admitted to [another facility] on 3/1/24 due to [a] history of removing wander guard and elopement. Her son agreed, and she was transported to a new facility on 3/1/24. The NHA or Designee called the door company [that] services the wander guard system. They came out on 3/1/2024 to adjust doors. However, as of 3/5/24, doors continue to not consistently lock and alarm with a wander guard. On 3/5/24 the door company was contacted to return and further evaluate and repair the front door. Beginning on 2/29/24, 24 hours, seven day per week, a staff member has been stationed at the door until the door can be adjusted to decrease the time it takes the door to close once opened, ensure the door locks and alarms when a resident approaches with a wander guard, ensure the door alarms if the door was already open and a person with a wander guard approaches. The staff person will remain at the front desk 24 hours per day, seven days per week until the front door, alarms and locks as a resident with a wander guard approaches, and when the front door still alarms if open already and a resident with a wander guard approaches. The NHA will verify the door is working properly by checking the door with a wander-prevention device prior to discontinuing the front desk person monitoring the door. The door will alarm and lock when a resident with a wander-prevention device approaches. When the door is open, the door will alarm if a resident with a wander prevention device approaches. As of 2/29/24, the elopement management binder, which includes pictures of residents with elopement risks, will be available at the front desk. The person stationed at the door was educated on the elopement management binder by the NHA on 2/29/24. Plan: On 2/29/24, All residents were reevaluated for elopement risk utilizing the elopement risk assessment form or evaluation in electronic record. Residents found to be at risk of elopement were evaluated by the IDT (interdisciplinary team) to determine appropriate interventions. Residents determined to require a wander guard have a consent, care plan, orders were updated to include placement of device monitoring every shift for function and placement completed 3/4/24. On 2/29/24, The DON or designee audited the elopement risk evaluations to match the care plans, completed on 3/4/24. On 2/29/24, the facility revised its pre-admission screening intake form to include a question about history and frequency of wandering and elopement by the Admissions Director. This will be an ongoing process and interventions will be put in place on admission as appropriate for wandering/elopement risk. Beginning on 2/29/24, The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place by the next business day. This will be ongoing. The licensed nurses will be educated beginning 3/5/24 to implement elopement interventions if a resident was assessed at risk for elopement on admission. The IDT will review the assessment the next business day for further intervention or continued risk. Beginning 2/29/24, new hires will receive education on wandering and prevention, wander guards, elopement procedure, and resident safety on day one of employment by the DON, Director of Social Services, or designee(s). On 3/5/24 the facility revised the Elopement policy to include prevention of elopement. Facility staff were educated on the new policy beginning 3/5/24. Staff who have not been educated will be educated prior to the start of their next shift. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for at least three months or until the pattern of compliance is maintained. A QAPI meeting was completed on 3/1/24. The QAPI committee reviewed the elopement, policies and procedures and reviewed interventions that can be used for residents attempting to elope, including utilizing outdoor areas. E. Removal of immediate jeopardy The immediate jeopardy situation was removed on 3/7/24 at 2:50 p.m., based on the implementation of the actions set out in the plan to prevent elopements and to maintain resident safety. However, the deficient practice remained at a G level, isolated, actual harm. II. Facility policy on 2/29/24 when the survey began The Elopement policy, revised in December 2007, was received from the NHA on 2/29/24 at 10:00 a.m. The policy documented in pertinent part, Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing (DON). If an employee observes a resident leaving the premises, he or she should attempt to prevent the departure in a courteous manner, get help from other staff members in the immediate vicinity, instruct another staff member to inform the charge nurse or the DON that a resident left the premises. When a departing individual returns to the facility, the Director of Nursing Services or Charge Nurse shall examine the resident for injuries, notify the attending physician, and notify the resident's legal representative (sponsor) of the incident. The policy did not include any procedures to prevent resident elopement. III. Facility failure to prevent resident elopement and to implement a comprehensive and effective approach to prevent further elopements. Observations on 2/29/24 at 9:15 a.m. revealed the facility was located next to a main highway with heavy road traffic. A. Resident #1 1. Resident status Resident #1, age 85, was admitted on [DATE] and discharged to the hospital on 2/19/24 following an elopement, fall, and hip fracture on 2/19/24. The resident did not return to the facility. According to the February 2024 computerized physician orders (CPO), diagnoses included Alzheimer's dementia, anxiety, muscle weakness, and abnormal gait. The 1/10/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of two out of 15. He was independent with personal hygiene and required supervision with toileting, partial staff assistance with dressing, and supervision with transfers and ambulation. The assessment documented the resident did not wander and did not have a wander-prevention device. 2. Record review On 1/3/24, a wandering assessment documented the resident was at risk of wandering with a wander risk score of 30 due to being fully ambulatory, disorientated and confused, wandering aimlessly, voicing a desire to leave, and history of elopement attempts. A score of 10 or higher was a wandering risk. On 10/13/23, the resident had orders for a wanderguard (wander-prevention device) due to a lack of safety awareness. There were no orders to check the placement or function of the wander-prevention device. The elopement care plan initiated on 10/13/23 documented the resident was at risk of elopement due to elopement/exit-seeking related to altered cognitive status, dementia, exit-seeking behaviors, and forgetfulness. Interventions, dated 10/13/23, included allowing wandering in safe areas, attempting to refocus when exhibiting behavior, checking door alarms promptly to ensure safety, elopement bracelet at all times, and check placement every shift. The progress notes were reviewed on 2/29/24 at 4:00 p.m. -On 2/19/24 at 2:03 p.m., the nursing progress notes documented the nurse spoke to the resident's son and told the resident's son the resident did have a wander-protection device on when he eloped from the facility that morning. On 2/19/24 at 3:21 p.m. the nursing notes documented the resident eloped from the facility that morning with another resident around 9:30 a.m. to 10:00 a.m. The resident was admitted to the hospital with a possible hip fracture after falling outside. B. Resident #2 1. Resident status Resident #2, age 74, was admitted on [DATE] and discharged on [DATE]. According to the February 2024 CPO, diagnoses included major depression and a history of delirium. The 1/10/24 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of six out of 15. She required set-up assistance with personal hygiene and toileting and required supervision with dressing and transfers. The assessment documented she did not wander and did not wear a wander-prevention device. 2. Record review On 1/3/24, a wandering assessment documented the resident was at risk of wandering with a wander risk score of 16 due to confusion, medications, and cognitive impairment. On 1/23/24, the resident had orders for a wander bracelet to the right wrist due to wandering and exit-seeking behaviors. Instructions were to check placement and function every shift. The elopement care plan initiated 1/3/24, documented the resident was at risk of elopement related to delirium and dementia. Wanderguard placed for safety. On 1/3/24, the interventions were to allow wandering in safe areas, approach in calm non threatening manner, attempt to refocus when exhibiting behavior, check door alarms to ensure safety, wander prevention device bracelet to right wrist, encourage expression of feelings, and redirection. On 1/23/24 a wander-prevention device was again added to the care plan. On 2/25/24, five days after the resident eloped, the care plan documented administer medications as ordered, assure identification band is in place, keep photograph in risk for elopement binder, assess for placement in specially designed therapeutic unit, monitor whereabouts frequently, reassure the family or significant other knows where they are. The progress notes were reviewed on 2/29/23 at 2:30 p.m. The nursing progress notes documented the following: -On 1/28/24 at 5:06 p.m. the progress notes documented the resident was very confused and exit-seeking all day. The resident was trying to open every door and looking for her car to go home. -On 2/1/24 at 2:26 p.m., a social service note documented the resident occasionally exit seeks and wanders. On 2/19/24 at 1:24 p.m., a nursing progress note documented a new wander-prevention device was placed on the resident's right ankle. On 2/19/24 at 2:34 p.m. the nursing notes documented the resident eloped the building today around 9:30 a.m. to 10:00 a.m. The resident came back to the building around 11:00 a.m. The resident was missing her wander-prevention device from her right wrist. She had no injury. IV. Facility investigation A. Investigation file The NHA provided an investigation file of the 2/19/24 elopements on 2/29/24 at 10:00 a.m. The file contained the following: A timeline documented on 2/19/24 at 7:30 a.m., the residents (Resident #1 and Resident #2) got up at 7:30 a.m. They ate breakfast at 8:15 a.m. in the 400 hall dining room. At 9:00 a.m. the nurse administered medication. Between 9:15 a.m. and 9:30 a.m., certified nurse aide (CNA) #1 escorted the residents to the activity room for group activities. Between 10:00 a.m. and 10:13 a.m., the residents left the activity room and went walking in the neighborhood. At 10:15 a.m., a call was received from the police that they had two of the facility's residents. The residents were two and a half blocks away from the building. Two facility leadership members went to escort the residents back to the facility. One resident came back, and the other went to the emergency room . A separate timeline dated 2/29/24, signed by the director of nursing (DON) documented the DON arrived at the facility on 2/19/24 around 10:10 a.m. There was no receptionist at the desk. The business office manager (BOM) notified the DON the police had called and said they had found two of [the facility's] residents (Resident #1 and Resident #2). That was around 10:13 a.m. The DON went to the 400 hall where both residents resided to look for them. LPN (licensed practical nurse) #5 told the DON some residents had gone to activities. CNA #1 was sent to the activities area to look for Resident #1 and Resident #2. They were not there. CNA #1 said he had taken both residents to the activity area around 9:30 a.m. The two admissions office staff got in their car and went to the hospital. The admissions staff brought Resident #2 back to the facility, and Resident #1 had been admitted to the hospital. The police came to the facility and took a report. A document titled, Elopement Contributing Factors, undated, documented, no receptionist at the front desk during reception hours, residents left group activities without an escort, [wander-prevention] system did not prompt the door to lock down, the sensor on the [wander-prevention] system was too narrow. The residents had to get inches from the door before it secured. The facility had no security system which could have movement sensors to notify leaders. A witness statement from LPN #5, dated 2/20/24, documented that on 2/19/24, between 9:00 a.m. and 9:30 a.m., the residents were sitting in the dining room watching television. A witness statement from CNA #1 documented she saw the residents around 9:00 a.m. to 9:30 a.m. a little after breakfast. The statement read that after breakfast, the CNA collected trays, took a resident to activities, and then returned to the floor. In the investigation file, attached to an in-service sign-in sheet, was a document titled, Tips for Elopement, dated 2/20/24. It documented, Involve the family in the prevention strategy by supervising residents during key risk times. Room placement for easy observation. React to statements such as l want to go home. Observe for aimless wandering, fear, or anxiety about the surroundings, involve the activities department in the prevention strategy; involve residents in small groups and activities that engage the resident's attention at key risk times. Consider the value of reality orientation (may not be appropriate for cognitively impaired residents). Review physical plants to be sure door alarms are working and that unauthorized areas are properly locked to prevent resident entry. Consider the use of a Chain of Custody'' for high-risk residents; develop a schedule for periodic checks on the resident. When the resident is involved in other activities or disciplines in the facility, such as dining and activities programs, the nursing assistant may give responsibility to that department for the periodic check, until the resident is returned to the assigned nursing assistant. Never assume everyone knows the resident is a wanderer; make it clear to dining room aides, new staff, and whoever is involved in the resident's care even for a short period of time. Consider the use of color-coded wristbands as an alert to staff. Consider the use of a personal alarm for the resident. Involve the resident in activity groups with small supervisory ratios; Avoid large group activities where supervision is minimal. An in-service form dated 2/20/24 documented all cognitively impaired residents should be escorted to and from activities and to alert nursing staff when residents are taken to activities and the dining room. A quality assurance and performance improvement plan (PIP) document dated 2/22/24 documented, on 2/19/24, All residents with [a wander-prevention device] will be identified. Residents with a [wander-prevention device] will have their [wander-prevention device] checked per orders, this education will be a return demonstration from the staff member that is checking the [wander-prevention device]. -Wander risk/Elopement risk assessments to be completed on all residents. Appropriate next steps to be taken including care plan updates, orders, notifications, consents. Attempts to ensure that there is facility identification for those that have [a wander-prevention device] will be done. -Education of all staff will be completed on the elopement policy and procedure. The elopement book will be kept up to date related to wandering or elopement assessment with a picture and a face sheet. Elopement drills will be completed monthly. Two-hour checks are encouraged for residents, and the [wander-prevention] system reviewed to ensure proper function on a routine basis. However, none of the tasks listed above had a person assigned or completion date. The columns for each of the items were blank. B. Interviews The DON and NHA were interviewed together on 2/29/24 at 11:35 a.m. -The DON said on 2/19/24, there was no receptionist at the desk when Residents #1 and #2 eloped because the receptionist was bringing a visitor to a resident's room. She said the business office manager (BOM) told her the police had called and said they had two of the facility's residents. She went to the 400 hall and the nurse on duty said Resident #1 and Resident #2 were in activities. The DON said she went to activities and the residents were not there. She said they must have left activities and gone out the front door. She said Resident #2 had her car keys all the time, and Resident #1 liked to go in a car for rides. She said Resident #1 must have fallen when he eloped and a good Samaritan called the police. Resident #2 was brought back to the facility. She did not have her wander-prevention device on. -The DON said there was a lag time on the front door when it was opened, to allow people with wheelchairs to get through without the door closing on them. She said the door did not alarm when it was in the open position and she had timed it to take two minutes to close once opened. The DON believed that was how the residents left the facility. She said the facility had a plan to ensure the receptionist was always at the front door during the day until the door could be looked at by a door company. V. Facility failure to implement a comprehensive and effective plan to prevent future elopements Interviews, record review, and observations revealed multiple failures in the facility's response to Resident #1 and #2's elopement on 2/19/24. A. Failures identified 2/29/24 1. Staff training post 2/19/24 incident LPN #1 was interviewed on 2/29/24 at 9:27 a.m. She said she was from a staffing agency. LPN #1 said she did not know who was at risk for wandering, but the facility had a binder with pictures of those who were at risk for wandering. The Elopement binder at the nurses'station was reviewed on 3/4/24 at 10:00 a.m. The binder contained a photograph of Residents #1, #2, #3, #14, #15,#19, #20, #21, and #22. The binder contained an in-service sheet that documented, Elopement Training, see attached. However, there was no documentation attached. LPN #1 had signed the inservice. The unit manager (UM) was interviewed on 3/4/24 at 9:37 a.m. as she approached the desk where the binder was located. -The UM agreed there was no information attached to the in-service. She said she gave the staff a verbal in-service. The UM could not say how staff were educated on the days she was not present at the facility. She said she would add written education on elopement to the elopement binder for the staff to review. -The UM said she was aware of the elopement of Resident #1 and Resident #2 on 2/19/24. She said the NHA completed the investigation and she did not know what the outcome was. The UM said she thought both residents were supposed to have a wander-prevention device on and she thought they left through the front door. -The UM said she did not know what the plan was to prevent future elopements because she was not involved in the investigation. The UM said she was responsible for educating the staff on who was at risk for elopement and to watch for things like aimless wandering or sitting by exit doors. 2. Wander-prevention devices Records for Residents #14, #15, and #21 were reviewed. All three residents were identified as at risk for wandering. The residents had orders for a wander-prevention device. However, there was no order or instruction on their care plans to check the function of the devices every shift, only to check the placement of the devices. Records for Resident #3 were reviewed and revealed on 2/21/24, a wandering assessment documented that Resident #3 was at risk of wandering with a wander risk score of 26 due to confusion, medications, and cognitive impairment. A score of 10 or higher was a wandering risk. An elopement care plan dated 2/20/24 documented Resident #3 was at risk for elopement related to dementia and forgetfulness. On 2/25/24, the care plan documented the elopement bracelet at all times, check placement every shift, check, check door alarms promptly. However, Resident #3 did not have an order for a wander-prevention device. 3. Wandering system On 2/29/24 at 11:30 a.m., the weekly exterior door checks were received from the maintenance supervisor (MS). The door checks read to check the operation of door monitors and resident wandering systems. The exterior door checks for 2/19/24 were stamped as completed on time 2/23/24 and included the main entrance/front door. Before 2/19/24, the door checks were documented as completed on 2/13/24 and completed on time 2/16/24. -There was no documentation to show the entrance/front door was checked after Resident #1 and #2 eloped on 2/19/24. On 2/29/24 at 9:00 a.m., there was no receptionist observed for several minutes at the front entrance, contrary to the facility investigation documents (see above) that read the facility's plan post 2/19/24 was to have the receptionist monitor the area during the day. On 2/29/24 at 11:35 a.m., the DON and NHA were interviewed together. -The DON confirmed the facility plan was to ensure the receptionist was always at the front door during the day until the door could be looked at by a door company. She acknowledged, however, that there was no receptionist at the front door today, 2/29/24 at 9:09 a.m. -The NHA said she has a receptionist at the desk monitoring the door until 5:00 p.m. and acknowledged there was no receptionist after 5:00 p.m. because the door automatically locks at 5:00 p.m. The DON, too, said at night the door could be locked and not opened, even by pushing on the door for 15 seconds. On 2/29/24 at 11:48 a.m. the front door was observed with the DON. The door was approached with a wander-prevention device in hand. The door did not react or alarm. Two more wander-prevention devices were obtained from the DON. The door was checked again with a different wander-prevention device. The door did not alarm or lock when approached with the wander-prevention device. The door was then opened. The door closed slowly, around 2 minutes. The door was approached with a wander-prevention device as it was closing. It did not alarm. On 2/29/24 at 12:34 p.m., eight residents who were assessed to need wander-prevention devices were observed with the UM. Resident #2, again, did not have a wander-prevention device on. Resident #3, who was assessed to be an elopement risk and had a care plan for a wander-prevention device (see above), did not have a wander-prevention device on. The UM said both residents should have had a wander-prevention device on. On 2/29/24 at 12:38 p.m., LPN #1, who was assigned to Resident #2, was interviewed again. She repeated that she worked for a staffing agency and she did not know Resident #2. She said she did not know if Resident #2 wore a wander-prevention device or had one on. On 2/29/24 at 12:55 p.m., the DON was interviewed again She said Resident #2 had a wander-prevention device yesterday and she must have removed it. She said she did not know what the plan was to keep Resident #2 safe if she was removing the wander-prevention device. On 2/29/24 at 1:00 p.m., the maintenance supervisor (MS) was interviewed. -The MS said he did not know if the front door locked automatically at 5:00 p.m. which the NHA had reported was the reason the facility only had a receptionist at the front desk until 5:00 p.m. He said he did not think the doors were locked automatically at 5:00 p.m. He said the doors should still open when the release bar on the front of the door was pressed for 15 seconds. He said he had never tested the doors after 5:00 p.m. to see if they were locked. -The MS said the front doors had been a problem since he started working at the facility in September 2023. He said sometimes the doors would not open even when a wander-prevention device was not nearby. He said he was not aware the door was not alarming when approached with a wander-prevention device (see above). He said he checked the facility doors leading to the exterior weekly to ensure the doors operated correctly and the wander-prevention system worked. On 2/29/24 at 1:35 p.m., the NHA was interviewed again. She looked up Residents #14, #15, and #21 on her computer. She said she did not see orders to check the function of the residents' wander-prevention devices, just to check the placement. She said the facility had reviewed residents at risk for wandering in the quality assurance and performance improvement (QAPI) meeting on 2/22/24. She said the committee reviewed residents for placement of wander-prevention devices but had not looked at checking the function of the devices. On 2/29/24 at 6:07 p.m., the regional director of plant operations (RDPO) was interviewed. He said the goal was to get the door to at least alarm with the approach of a wander-prevention device and the door was open. He said there was a sensor on the wall several feet before the front door that should trigger the door to alarm and lock but it was not working. He said the doors do not lock after 5:00 p.m. and always open when the release bar on the front of the door is pressed for 15 seconds. B. Failures identified after 2/29/24 1. Staff training On 3/4/24 at 9:34 a.m., the regional director of clinical services (RDCS) #1 was interviewed. RDCS #1 provided staff training records to prevent elopements pe[TRUNCATED]

Based on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for two (#17 and #8) of three residents reviewed for pain management out of 38 sample residents. The facility failed to ensure Resident #17 and Resident #8, both with a diagnosis of chronic pain, were assessed for pain accurately and administered pain medications as ordered. Both residents reported increased levels of pain. Resident #17's 2/19/24 pain assessment documented the resident had pain which affected her day to day activity. On 2/29/24, the resident reported she did not always get her pain medication as ordered. She said her pain affected her sleep and her ability to get around. Resident #8's 2/21/24 pain assessment documented the resident had pain which affected his sleep and his day to day activity. On 2/29/24, the resident reported he had gone without pain medications on several occasions. He said he was not able to sleep or move around much when he had increased pain. Due to the facility's failures to ensure Resident #17 and Resident #8's pain medications were consistently administered as ordered, both residents sustained increased pain. Findings include: I. Facility policy and procedure The Pain policy, revised October 2022, was received from the director of nursing (DON) on 3/5/24 at 4:09 p.m. It read in pertinent part, The physician and staff will identify individuals who have pain or who are at risk for having pain. This includes reviewing known diagnoses and conditions that commonly cause pain; for example, degenerative joint disease, rheumatoid arthritis, osteoporosis (with or without vertebral compression fractures), diabetic neuropathy, oral or dental pathology, and post-stroke syndromes). It also includes a review for any treatments that the resident currently is receiving for pain. With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain with minimal medication side effects, less frequent headaches, or improved functioning, mood, and sleep. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. II. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included septic right knee, lumbar abscess and chronic pain syndrome. According to the 2/19/24 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required substantial maximal assistance from staff with transfers, dressing, toileting and personal hygiene. She required moderate assistance from staff with bed mobility. The assessment documented she had pain which affected day to day activity. B. Resident interview Resident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said the facility would run out of her scheduled and PRN (as needed) pain medication Norco (opioid pain medication). Resident #17 said the nurse would try to offer her muscle relaxers when the facility ran out of the Norco, however, she told them the muscle relaxer was not as effective as the pain medication. Resident #17 said she had two back surgeries for infections in her back, however, she continued to have back pain and chronic pain in her knees. Her pain level was 6 to 8 (on a scale of 1-10, with 10 being the worst pain) when she did not get the pain medication. She said it affected her sleep and her ability to get around when she had pain. Resident #17 said the lowest her pain level got was a two out of 10. C. Record review Review of Resident #17's February 2024 CPO revealed the following physician's orders: Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 milligrams (mg). Give one tablet by mouth every four hours PRN for pain, ordered 1/30/24. -There were no parameters for when to give the medication. Celebrex capsule (Celecoxib) 100 mg. Give one capsule by mouth two times a day for pain, give with meals, ordered 2/19/24. Hydrocodone-Acetaminophen oral tablet (Norco) 5-325 mg. Give one tablet orally three times a day for chronic pain, ordered 2/20/24. The January 2024 and February 2024 medication administration records (MAR) documented the resident had received the Norco PRN pain medication for pain levels of 0 to 8 out of 10. The February 2024 MAR further revealed the resident was given Norco PRN two to three times per day from 2/1/24 until the order was changed to scheduled three times per day on 2/20/24. -Despite nursing staff documenting Resident #17 was administered Norco two to three times per day PRN, the resident's pain assessment levels on the MAR for the administration of the Norco were frequently documented at a 0 out of 10. From 2/20/24 (after the Norco PRN physician's order was changed to scheduled Norco) until 2/24/24, the Norco medication was signed off as administered on the February 2024 MAR each day, including three doses on 2/24/24. -However, review of the Norco narcotic count sheet revealed no Norco was administered on 2/24/24. -On 2/20/24, at 8:31 a.m. and 4:49 p.m., Resident #17's Celebrex was documented as not administered for pain because it was not available. D. Staff interview The DON was interviewed on 3/6/24 at 10:23 a.m. She said she had compared the Norco narcotic count sheet to the February 2024 MAR. She said the resident had missed doses of Norco despite being signed off on the MAR as given. The DON said she found no evidence the Norco was taken from the facility's emergency medication supply which meant the pain medication was not administered to the resident. The DON said PRN pain medications should have parameters for when to give them. The DON said she would not expect Norco to be given for pain levels of zero. The DON said she would begin in-servicing the licensed nurses on pain control and medication administration. III. Resident #8 A. Resident status Resident #8, age 68, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included osteoarthritis and chronic pain. According to the 2/21/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. He was independent with bed mobility and transfers. He required set up assistance for the staff with toileting, dressing, and personal hygiene. He had pain and was on pain medication. The assessment documented pain affected the resident's sleep and day to day activity. B. Resident interview Resident #8 was interviewed on 3/4/24 at 10:15 a.m. Resident #8 said the nurses documented his pain medications (Oxycodone) and neurontin were given but they did not give him the medications. Resident #8 said sometimes the nurse would say they did not have the medications. He said he had gone without his pain medications for several days before. He said when he did not receive his pain medications he had increased pain at a pain level of 8 out of 10 and was not able to sleep or move around as much. Resident #8 said he had reported not receiving his pain medications consistently to the DON but he said he had never heard anything back from her. He said his pain levels were consistently at a level of 4 out of 10 when he received his pain medication but he always had pain. Resident #8 said his pain was never a pain level of 0 out of 10. C. Record review Review of Resident #8's February 2024 CPO revealed the following physician's orders: Gabapentin oral capsule 300 mg. Give 600 mg by mouth at bedtime for neuropathic pain, ordered 8/17/23. Tizanidine oral tablet 2 mg. Give one tablet by mouth two times a day for muscle spasms, ordered 1/25/24. Oxycodone oral capsule (Oxycodone HCl) 5 mg. Give 10 mg by mouth four times a day for right knee pain, ordered 8/22/24. Review of Resident #8's electronic medical record (EMR) revealed the following progress notes: On 1/12/24 at 9:35 a.m. the nursing progress notes documented the resident did not get his oxycodone because it was on order. On 1/16/24 at 11:31 a.m., 3:02 p.m. and 8:00 p.m. the nursing progress notes documented Resident #8 did not get his scheduled oxycodone because it was on order from the pharmacy. On 1/26/24 at 4:05 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 1/28/24 at 4:40 p.m. the nursing progress notes documented the resident's Tizanidine for muscle spasms was not given because it was on order. On 2/1/24 at 7:30 p.m. the nursing progress notes documented the resident did not receive his gabapentin for nerve pain because it was on order. On 2/2/24 at 4:45 a.m. the nursing progress notes documented in a behavior note, the resident said I want all my medications. The nurse responded, If it is not on my cart, I can not give it to you. -The missing medications were not documented. -There were no further progress notes regarding action taken to get the medication or that the physician was notified for further orders. The oxycodone narcotic count sheets were reviewed for January 2024. -There was no oxycodone signed out for any of the four dose administration times on 1/12/24, and only one of the four dose administration times (8:00 a.m.) was signed out on 1/16/24. The January 2024 MAR documented the resident had a pain level of five on 1/16/24 at 10:00 p.m. when he did not receive his oxycodone. -The resident's pain levels for the rest of January 2024 and February 2024 were frequently documented as a 0 out of 10, despite the resident's report that his pain level was never below a 4 out of 10, even when he received pain medication (see resident's interview above). -However, Resident #8 reported his pain level never went below a 4 out of 10, even when he received pain medication (see resident's interview above). -The last comprehensive pain assessment completed for Resident #8, other than the 2/21/24 MDS assessment, was on 8/17/23, six months prior to the survey. The assessment documented that the resident had frequent pain at a level of 6 out of 10. -There was no documentation of the resident's pain goals or things that made pain worse or relieved pain. D. Staff interview The DON was interviewed on 3/5/24 at 2:06 p.m. The DON said the licensed nurses should have notified her when they did not have the pain medication for Resident #8. She said the medication could be received from the pharmacy within two hours when requested STAT (urgent) from the pharmacy. The DON said comprehensive pain assessments were completed on admission, quarterly and as needed. She said pain was assessed every shift and documented on the MAR. She said PRN pain medication should have parameters for when to administer the medication. IV. Additional interviews The DON was interviewed again on 3/5/24 at 4:01 p.m. She said the regional nurses had reviewed the MARs and progress notes for Resident #17 and Resident #8 and said the residents did not receive their pain medications as ordered. She said this was an issue. The DON said she would investigate further to see if there was a trend with specific nurses. She said the facility had an emergency medication system where the medication could have been obtained. The DON said the nurses should have notified the provider for further orders when the pain medication was not available. The DON said she would begin educating the staff on steps to take when a narcotic pain medication was not available and obtaining parameters for when to administer pain medication. The DON said she was not sure if the frequent pain level of 0 out of 10 documented on the MARs for both residents was accurate.

Based on record review and interviews, the facility failed to ensure four (#18, #7, #3 and #15) out of four residents reviewed out of 38 sample residents were protected from resident to resident physical abuse by Resident #6 and Resident #14. Resident #6 admitted on [DATE] with a history of aggression. Between 1/17/24 and 1/18/24, Resident #6 was involved in at least three altercations with Residents #18, #7 and #3. The altercation with Resident #3 resulted in Resident #3 being transferred to the hospital for head trauma where he received twelve staples to his head. The facility was aware Resident #6 was wandering into other residents' rooms but failed to implement a plan to monitor the resident and redirect her from other residents. Additionally, the facility failed to implement a plan to prevent physical abuse to Resident #15, by Resident #14 who had known aggressive behavior. Findings include: I. Facility policy The Abuse and Neglect policy, revised March 2018, was received from the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. The policy documented in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. The nurse will assess the individual and document related findings. The nurse will report findings to the physician. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. The medical director will advise facility management and staff about ways to ensure that basic medical, functional, and psychosocial needs are being met and that potentially preventable or treatable conditions affecting function and quality of life are addressed appropriately. The physician will advise the facility and help review and address abuse and neglect issues as part of the quality assurance process. II. Resident to resident physical abuse by Resident #6 to Resident #18 A. Incident on 1/17/24 On 1/17/24 at 11:20 a.m., the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room calmly when Resident #6 repeatedly went into Resident #18's room. Resident #18 asked her to stop coming into his room. When Resident #18 was not looking, Resident #6 took his cane. Resident #18 yelled for the nurse. When the nurse went into the room Resident #18 was pulling Resident #6's hair. The residents were separated, and the facility had decided to move Resident #6's room for safety concerns. Resident #6 was encouraged to socialize with residents in common areas and not in resident rooms. On 1/17/24 at 11:34 a.m. the nursing progress notes for Resident #6 documented Resident #18 was sitting in his room and calm. Resident #6 repeatedly went in Resident #18's room even though the nurse asked her not to. Resident #6 took Resident #18's cane. When the nurse arrived Resident #18 was pulling Resident #6's hair. Resident #6 said she was punched. The NHA recovered Resident #18's cane. There were no injuries noted for either resident and Resident #6 agreed to a room move for safety concerns. On 1/17/24 at 4:57 p.m. a Change of Condition Evaluation documented Resident #6 was involved in a physical and verbal altercation. The evaluation documented Resident #6 was verbally and physically aggressive. The 1/17/24 facility investigation was received from the nursing home administrator (NHA) on 3/4/24 at 10:00 a.m. The investigation documented the Resident #6 and Resident #18 were immediately separated and there were no injuries to either resident. The investigation file contained a follow up statement from Resident #18 on 1/18/24 stating he was doing better and no longer upset. The investigation contained two resident interviews. One resident said they had heard about residents fighting on 1/17/24 and one resident said another resident had tried to punch her wheelchair and she had to tell him to stop. -There were no further resident interviews and no staff interviews found in the facility's investigation file. -The investigation documented that no agencies were notified such as the police, ombudsman or State Agency (cross reference F609 for failure to report an alleged violation). B. Resident #6 1. Resident status Resident #6, less than age 65, was admitted on [DATE] and discharged to the hospital on 1/18/24. According to the January 2024 computerized physician orders (CPO), diagnoses included traumatic brain injury (TBI), alcohol abuse, bulimia nervosa (eating disorder), encephalopathy (alteration in brain function or structure), borderline personality and major depression with severe psychotic symptoms. According to the 1/12/24 minimum data set (MDS) assessment, the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. The assessment documented the resident had symptoms of feeling down, hopeless, trouble concentrating with little pleasure in doing things. The assessment documented the resident did not wander but had a wander prevention device. 2. Record review A Preadmission Screening and Resident Review (PASRR) Level II Notice of Determination (NOD) for Mental Illness (MI), dated 12/18/24, documented Resident #6 had an open legal case for felony menacing and Resident #6's representative reported Resident #6 had been exhibiting aggressive behavior. The PASRR Level II was in the facility medical record for Resident #6 and had a printed date in the corner of 1/12/24. Resident #6's behavior care plan, initiated 1/15/24, documented Resident #6 wandered into other resident rooms and took or touched their belongings. The goal was the resident would accept supportive strategies and demonstrate adequate control of emotions which would not result in injury to self or others. Interventions included, administer medications as ordered, document behavior, encourage resident to verbalize feelings, establish rapport, maintain a calm, slow, understandable approach, notify the physician, responsible party of aggression and abusive behavior, observe and document changes in behavior, including frequency of occurrence and potential triggers, observe for clinical factors influencing behavioral indicators, observe resident's mood and response to medication, referred for psychiatry services -The care plan did not have interventions to address the resident's known behavior of wandering into other resident rooms and taking their belongings. C. Resident #18 1. Resident status Resident #18, less than age 65, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included schizoaffective disorder, major depression, personality disorder, post traumatic stress disorder (PTSD) and traumatic brain injury (TBI). According to the 1/12/24 MDS assessment, the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. He was independent with personal hygiene, toileting, dressing, bed mobility, transfers and ambulation. D. Staff interviews The NHA and the director of nursing (DON) were interviewed on 3/5/24 at 10:23 a.m. The NHA said she remembered Resident #6 took Resident #18's cane. The NHA said Resident #6 did take Resident #18's cane and the NHA found it and returned it to Resident #18. The NHA said Resident #18 then pulled Resident #6's hair. The NHA said there were no further interviews of residents because the residents on that unit could not tell staff what was going on. She said the facility had to look for non verbal things. -However, the NHA could not describe what non verbal things were looked for. The NHA said she did not notify the police because she did not have time to. She said she would notify them. The NHA said she notified the ombudsman after the second incident (see below). The NHA said Resident #6 agreed to a room move. She moved to a room on the 300 hall. III. Resident to resident physical abuse by Resident #6 to Resident #7 A. Interviews regarding the incident on 1/17/24 A frequent visitor (FV) was interviewed on 3/4/24 at 2:38 p.m. The FV said she had several serious complaints regarding the facility. She said she was told Resident #6 placed a blanket around Resident #7's face. She said Resident #7 had been unable to move to protect herself. The FV said Resident #6 was then moved to a new hall where she assaulted Resident #3, resulting in 12 stitches to his face and his entire face was black and blue (see below). The FV reported that residents and staff were feeling unsafe and afraid to report facility issues such as abuse. The FV said the staff were told not to report the abuse by the DON and that she would handle it. The FV said she called the police as well as other resident family members and reported the incidents. The FV further said staff were told not to speak to the State Agency by the NHA or there would be consequences. A restorative nurse aide (RNA) was interviewed on 3/6/24 at 1:00 p.m. He said he was present the day Resident #6 assaulted Resident #7. He could not remember the exact day it occurred. He said he remembered staff were scrambling around to keep Resident #6 out of Resident #7's room because Resident #6 had turned off Resident #7's oxygen and was holding a blanket over her face. He said a staff member had to block the door so Resident #6 would not go back in the room with Resident #7. He said Resident #6 was moved to the 100 hall. The RNA said staff told him they were not to report the incident as abuse or that Resident #6 assaulted Resident #7, but to report it as a fall. The RNA said the facility had not provided any training in mental health or dementia (cross-reference F940 for failure to develop and implement an effective staff training program). The DON was interviewed again on 3/7/24 at 12:37 p.m. The DON said she was told Resident #6 was holding a blanket around Resident #7's face around 1/17/24. She said she was not at the facility that day. The DON said the NHA was at the facility and handled the situation. The DON said the NHA should have done an investigation but she did not (cross-reference F610 for failure to investigate an alleged violation). She said the nurse on duty witnessed the assault but she was an agency nurse and had not returned the DON's calls. The DON said she found out about the incident a few days after it occurred. The DON looked at her computer and said there was no assessment of Resident #7. She said Resident #6 was then moved to a new room and that was when she assaulted Resident #3 (see below). -The phone number and name of the agency nurse was requested and not received by the end of the survey on 3/7/24. -The NHA was unavailable for an interview. B. Resident #7 1. Resident status Resident #7, age 81, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses include Parkinson's disease, major depression and dementia. According to the 1/30/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of four out of 15. She was totally dependent on staff for transfers and toileting. She required substantial to maximal staff assistance with bed mobility, dressing and personal hygiene. C. Record review -There were no progress notes in Resident #6 or Resident #7's medical record regarding the alleged assault. -There was no investigation and the alleged assault was not reported to the State Agency or the ombudsman (cross-reference F609 for failure to report an alleged violation and F610 for failure to investigate an alleged violation). IV. Resident to Resident physical abuse by Resident #6 to Resident #3 A. Incident on 1/18/24 On 1/18/24 at 10:28 a.m., an interdisciplinary team (IDT) note documented Resident #3 was pushed by another resident and obtained a laceration to the right eyebrow. -There were no recommendations by the IDT team. On 1/18/24 at 11:54 a.m., the nursing notes documented the nurse heard Resident #3 fighting with the same female resident he had been fighting with all day (Resident #6). The nurse observed arms flying at each other and Resident #3 lost his balance and fell hitting his face on the ground. There was a deep head wound from his glasses. Resident #3 complained of chin pain. On 1/18/24 at 3:38 p.m., the nurse note documented 911(emergency services) was called because the laceration to the right eyebrow area on Resident #3 was too large to steri-strip. On 1/18/24 at 3:52 p.m., a change of condition form documented that at approximately 11:30 a.m., Resident #3 was pushed by another female resident. The nurse documented she heard screams and ran to the hall to see Resident #6 push Resident #3. Resident #3 was bleeding from the right eyebrow and it was too large to apply steri-strips to. On 1/18/24 at 4:33 p.m., the nursing notes documented Resident #3 returned to the facility from the emergency room with 12 staples above his right eye. On 1/19/24 at 11:30 a.m., a provider note documented Resident #3 was involved in an altercation with another resident causing him to fall and strike his head. He presented to the ER (emergency room ) with jaw pain and a large forehead laceration. On 1/20/24 at 11:30 a.m., the nursing notes documented Resident #3 continued with discoloration to his face after an altercation with another resident. The other resident had since been removed from the facility. On 1/21/24 at 3:53 a.m., the nursing notes documented Resident #3 continued with sutures to his head and bruising to the right eye, forehead and chin. The 1/18/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. The investigation documented Resident #3 and Resident #6 were immediately separated and Resident #6 was sent to the ER for a psychiatric evaluation. A social services interview in the investigation file, dated 1/18/24, documented Resident #3 said Resident #6 pushed him and was trying to do harm to me. A second social services note documented that, per staff, Resident #6 had been continuously wandering to Resident #3's unit. Staff had redirected her back to her own unit. Five resident interviews dated 1/19/24 did not document further abuse. -There were no further staff interviews. -There was no documentation the State Agency, police or ombudsman were notified. (cross-reference F609 for failure to report an alleged violation). B. Resident #3 1. Resident status Resident #3, age 71, was admitted on [DATE] and readmitted on [DATE]. According to the March 2024 CPO, diagnoses included intracranial hemorrhage (brain bleed), schizoaffective disorder and dementia. According to the 2/21/24 MDS assessment, the resident had severe cognitive impairment with a BIMS score of seven out of 15. He required supervision with dressing and transfers, and was independent with personal hygiene, bed mobility and toileting. C. Interviews Resident #8 was interviewed on 3/4/24 at 10:15 a.m. He said a female resident had assaulted a male resident and the police were not notified. He said the staff, a frequent visitor and a resident representative had called the police and there was now a detective involved. He provided a case number and the name of a detective. The NHA and the DON were interviewed together on 3/5/24 at 10:23 a.m. The DON said Resident #6 wandered into other resident rooms. She said she wandered into Resident #3's room and she pushed him. Resident #3 fell and cut his right eyebrow. Resident #6 was removed from the area. Resident #3 went to the ER and received seven or eight sutures. He had bruises on the right side of his face. The DON said Resident #6 was taken to the ER in the facility van for a psychiatric evaluation. The NHA said the resident wandered into other resident rooms. She wandered into the room of Resident #3. She pushed Resident #3 and he fell cutting his face. Resident #6 was then taken in the facility van to the hospital. However, Resident #6 jumped out of the facility van on the way to the hospital and was then taken by ambulance to the hospital and the facility discharged her. The NHA said the facility was not aware of the resident's history of aggression. She said the facility would be looking at referrals for new admissions more in depth. She said she would start approving residents with a history of aggression herself. The NHA said she did not know what the plan was to keep Resident #6 from wandering into other residents' rooms. She said the facility should have had a plan to monitor Resident #6 more closely. The social services director (SSD) was interviewed on 3/5/24 at 11:00 a.m. The SSD said he had not read Resident #6's PASRR Level II and was not familiar with her history. He said she was not here very long but shortly after she admitted she walked to the doorways of other residents and stared at them. This went on for a week. She had arguments with other residents, including Resident #18. The SSD did not recall exactly what happened with Resident #3. He said he remembered the residents were yelling at each other. He did not witness the altercation. He said he had noticed an increase in residents with mental health conditions coming into the facility since December 2023. The SSD said the facility had not provided any training in mental health, though he thought there should have been training. Licensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #4 said she was told by other staff members Resident #6 assaulted Resident #3. She said the police had not been notified by the facility but a resident's family member had notified the police. LPN #4 said she was familiar with Resident #6. She said Resident #6 kept wandering into Resident #3's doorway. Resident #3 would tell her to leave, but Resident #6 would say I do not have to The RNA was interviewed on 3/6/24 at 1:00 p.m.The RNA said shortly after he heard a female yelling come on, come on, he went to the hall and saw Resident #3 on the floor with a gash in his head, bleeding all over. He said he was told by other staff member that Resident #6 had a rock in her hand and hit Resident #3 with it. V. Resident to resident physical abuse by Resident #14 to Resident #15 A. Incident on 1/12/24 The 1/12/24 facility investigation was received from the NHA on 3/4/24 at 10:00 a.m. A staff witness statement, dated 1/12/24, documented Resident #15 was pushing a chair and mistakenly hit Resident #14's foot. Resident #14 pushed Resident #15 who fell on the floor. Resident #14 then began hitting Resident #15 in the face before being pulled off of the resident. Three residents who witnessed the event were interviewed. The residents were asked: -How are you feeling? -How do you feel after the incident? -Would you like to speak to your family or friends? -Is there anything I can do to help you cope with the incident? -There were no resident interviews about abuse. -There were no staff interviews about abuse. -There was no documentation the State Agency or police were notified (cross-reference F609 for failure to report an alleged violation). B. Resident #14 1. Resident status Resident #14, age 77, was admitted on [DATE]. According to the March 2024 CPO, diagnoses included paranoid personality disorder, restlessness and agitation, cerebral infarction (stroke), aphasia (speech disorder) and vascular dementia. According to the 12/20/23 MDS assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He required supervision with dressing, transfer and toileting. He required setup assistance with personal hygiene and was independent with bed mobility. The assessment documented the resident had delusions and verbal behaviors directed towards others. The assessment documented the resident's behavior had gotten worse and disrupted care, the living environment and interfered with social interactions. 2. Record review On 1/10/24 at 3:00 p.m., the progress notes for Resident #14 documented he was hit with a chair on the right side. There were no injuries. Resident #14's care plan, initiated 12/19/23, documented the resident was at risk for behavioral symptoms due to dementia and paranoid personality disorder. He had punched another resident at another facility. Interventions were to anticipate needs and meet promptly, document and record behavioral episodes, establish a rapport with the resident, maintain a calm, slow, understandable approach, manage environmental factors to optimize comfort, observe and document changes in behavior, including frequency of occurrence and potential triggers and observe resident's mood and response to medication. -There were no changes made to Resident #14's care plan after the altercation with Resident #15 on 1/10/24. C. Resident #15 1. Resident status Resident #15, age 85, was admitted on [DATE]. According to the February 2024 CPO, diagnoses included vascular dementia, anxiety and psychotic disorder with hallucinations According to the 12/4/23 MDS assessment, the resident had severe cognitive impairment and could not complete the BIMS assessment. The staff assessment for mental status documented the resident had long and short term memory loss. He was independent with bed mobility, and required supervision for dressing, transfers and toileting. He required set up assistance from staff with personal hygiene. The assessment documented he had physical and verbal behavior directed towards others. 2. Record review On 1/10/24 at 3:00 p.m., the nursing progress notes for Resident #15 documented Resident #15 was pushing furniture and accidentally ran into Resident #14 who then pushed Resident #15. Resident #14 continued to swat and hit Resident #15 with his hat. The residents were separated by staff. -There was no documentation about injuries. On 1/10/24 at 7:08 p.m., the nursing notes documented that Resident #15 had no injury. C. Staff interviews The NHA and DON were interviewed together on 3/25/24 at 10:23 a.m. The DON said Resident #15 was moving a chair around the nursing station. She said he used to be a janitor. He bumped into Resident #14 and Resident #14 pushed Resident #15 to the ground and began hitting him with his hat. The staff separated them. The DON said there were no injuries to either resident. The DON looked at both residents' electronic medical records(EMR) and said no changes were made to the residents' care plans following the incident. She said Resident #15 did have a history of aggression. She said he had post traumatic stress disorder from being assaulted by his wife. The NHA said she thought she notified the police and ombudsman around 1/12/24. -However, there was no documentation provided to indicate the NHA had notified the ombudsman about the incident.

Based on observation and interviews, the facility failed to effectively administer its resources to attain the highest practicable wellbeing for each resident. Specifically, the facility failed to: -Implement and maintain safety measures to prevent elopements with significant injury; -Prevent, report and investigate allegations of resident to resident abuse; and, -Provide sufficient leadership to address and/or avoid multiple significant concerns. Findings include I. Quality of care -Cross reference F689 for failure to ensure residents were free from accidents and elopement which caused major injury. -Cross reference F697 for failure to implement an effective pain management program. II. Freedom from abuse -Cross-reference F600 for failure to protect residents from physical abuse. -Cross-reference F609 for failure to report alleged violations. -Cross-reference F610 for failure to investigate alleged violations. III. Nursing services -Cross-reference F760 for failure to ensure residents were free from significant medication errors. IV. Training requirements -Cross-reference F730 for failure to ensure certified nurse aides (CNA) had completed required 12 hour training based on their date of hire and annual performance review. -Cross reference F940 for failure to ensure all direct and indirect care staff were trained in dementia care, mental health diagnoses and substance abuse. V. Quality assurance and performance improvement -Cross reference F867 for failure to implement effective systems to obtain feedback, use data, and take action to conduct structured, systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes that impact quality of care, quality of life, and resident safety. VI. Interviews A frequent visitor (FV) was interviewed on 3/4/24 2:38 p.m. The FV said she had several serious complaints regarding the facility. She said she had heard many residents complain about not getting their medications and that the environment was bad. She said residents and staff were afraid of retaliation from the administration for reporting things such as abuse. The FV said the facility had had a large influx of admissions with mental health and substance abuse diagnoses but the staff had not been offered any training in those areas. The FV said many residents had complained about roommates with mental health issues and requested to be moved to a new room, however, she said the residents' requests to move rooms were not being honored. The FV said Resident #7 was found with a blanket being held around her head by Resident #6. The resident could not defend herself due to her immobility. She said Resident #6 was then moved to another hall where she pushed Resident #3 down. She said the resident had head trauma and had to get 12 stitches. The FV said she saw his face which was completely black and blue. The FV said the facility staff told her they should report the abuse as a fall by the DON. The FV said neither she nor the police were notified of the incident. (Cross-reference F600 and F610). The FV said she was concerned for the safety of the residents and the staff were being intimidated and afraid to speak up. The FV was interviewed again on 3/6/24 at 11:43 a.m. The FV said the NHA led the facility by fear and retribution. The staff had been told during the current survey there would be consequences for talking to the state. She said the NHA dismissed what the staff and residents told her. Resident #17 was interviewed on 2/29/24 at 2:54 p.m. Resident #17 said Resident #4 threatened to harm her but there was no follow up by the administration. She said she had missed multiple doses of medication including pain medication (cross reference F697 and F760 significant medication errors). Resident #17 said the NHA and DON were aware of her concerns but there was no follow up. She said when NHA was dismissive of her concerns when she reported them and Resident #17 was made to feel like she was the problem. Resident #8 was interviewed on 3/4/24 at 10:15 a.m. He said he was told many staff had resigned due to poor management. He said he had missed several doses of his medications including pain medications. He said he had reported this to the DON but there was no follow up. He said a resident was beaten up by a female resident and the staff told him they were instructed by the DON not to call the police. He said there was a resident who drank alcohol and smoked in his room. He said residents and staff were fearful of him but nothing had been done to address the concerns. Resident #8 said the NHA did not follow up on concerns with abuse or other resident behaviors. He said she dismissed things and talked down to people. He said the corporation that provided oversight to the building needed to know what was happening at the facility. The restorative nurse aide (RNA) was interviewed on 3/7/24 at 1:00 p.m. The RNA said he was afraid to be seen talking to the state. He said the staff had been threatened and feared retaliation if they spoke up and he needed his job. He said one of the main problems was the lack of communication by the DON and the NHA. He said the NHA was overpowering conversations, and shutting down concerns reported by the staff. The RNA said things were falling apart. He said roommates were often put together who were not appropriate such as putting those with behaviors in with residents who were unhappy with the behaviors. He said abuse by Resident #6 had not been thoroughly investigated and the staff had been told to document the abuse as a fall by the DON. The RNA said there had been an increase in admissions of residents who had mental health conditions and behaviors but no training had been provided to the staff (cross reference F940). He said many staff were afraid of retaliation by the facility and were not going to say anything Licensed practical nurse (LPN) #4 was interviewed on 3/5/24 at 1:50 p.m. LPN #1 said she was concerned about the NHA finding out she was discussing things with the state surveyors. She said Resident #6 beat up Resident #3. She said the police were never called but a family member had heard about the abuse and called the police. She said the facility was admitting a lot more residents with mental health issues and behaviors but the staff had not received any training on how to handle the residents' behaviors. The NHA and DON were interviewed on 3/6/24 at 2:12 p.m. The NHA said the elopements were discussed but not in enough detail to identify and correct all of the issues such as Resident #2 removing her wanderguard. The NHA said she was not aware the smoking assessments had not been completed timely, and smoking assistive devices were not provided. She said they started accepting residents who smoked a few months ago but had not reviewed what the smoking program would entail. The NHA said the multiple missed medications and unavailability of medications was not identified. The NHA said the abuse investigations needed to be more thorough and she could not recall if she had reported them to the state or police.

Based on record review and interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, education, staff competencies and facility based risk assessments. Findings include: I. Facility policy and procedure -The Facility Assessment policy was requested from the nursing home administrator (NHA) on 3/6/24 at 8:45 a.m. and was not received by the end of the survey on 3/7/24. II. Record review The Facility Assessment, last reviewed by the facility on 3/1/24 (during the survey), was received from the NHA on 3/6/24 at 8:45 a.m. The facility assessment failed to include the following: -Staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff including those presidents with substance abuse or who where exit seeking, wandered; -Staff trainings/education necessary to provide the level and types of support and care needed for the resident population; and, -Identify facility resources needed and equipment to provide competent resident support during day-to-day operations and emergencies including the facility's wander prevention system. III. Staff interviews The NHA was interviewed on 3/6/24 at 8:45 a.m. The NHA said the facility assessment had many missing components. She said the facility assessment had several areas that were missing and had not been completed on the template used. The NHA said the facility assessment did not include trainings or competencies for the different staff members, information on the facility wander prevention system, facility or community risk assessment using an all hazards risk approach, description of the infection prevention and control program, list of contracts, recruitment and retention of medical practitioners, technology resources, ethnic, cultural, or religious considerations. The NHA said the emergency preparedness portion of the facility assessment had missing components such as a facility map. The NHA said she was not aware all of these items needed to be in the facility assessment.

Based on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 3/13/24 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf, read in pertinent part, Chemical sanitizers that are used to sanitize equipment and utensils shall be provided and available for use during all hours of operation. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact times and be used in accordance with the EPA registered label use instructions. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. II. Observations and interviews On 3/7/24 at 11:31 a.m., two red tubs of quat (benzalkonium chloride) solution were sitting on tables in the main kitchen. The dietary director (DD) said the solution was used to clean equipment and the metal tables where food was prepared. She said the staff checked the quat solution each shift and it should register 200 ppm. The DD said there was a machine that automatically mixed the solution with water and the staff only needed to refill the red buckets with it. -The solution was tested with test strips by the DD. The solution did not register on the strip. It remained at 0 ppm. -The DD dumped out the solution and retested the new solution with a new test strip. The new test strip continued to read 0 ppm. -The DD obtained a new package of test strips and tested the quat solution again. The solution tested 0 ppm again. The DD manager said she would call the company that installed the machine which dispensed the quat solution and have them come check the machine to figure out if there was an issue. She said she would use microkill wipes to clean the equipment and food preparation services in the meantime. She said she did not know if the wipes were food safe but she would find out. On 3/7/24 at 2:31 p.m., the DD said she was going to the store to purchase food safe wipes and would not use the microkill wipes because they were not food safe. The DD was interviewed again on 3/7/24 at 3:20 p.m. She said the company that installed the machine which dispensed the quat solution had come to inspect the machine. She said the problem was the facility had been using the wrong test strips to test the solution. The DD said the correct test strips had been obtained and the quat solution now tested at 200 ppm. -The test logs for February 2024 documented the quat solution tested at 200 ppm each shift. The DD said the test logs could not be accurate given the facility had the wrong test strips. She said she would be educating the dietary staff on how to test the quat solution. The DD did not know how long the facility had been using the wrong test strips.

Based on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to ensure all direct and non-direct care staff received training in dementia care, substance abuse and behavior management. Findings include: I. Facility policy The In-Service Training Policy, revised August 2022, was received from the regional director of clinical services (RDCS) #1 on 3/11/24 at 11:44 a.m. The policy documented in pertinent part, Required training topics include the following: Behavioral health, dementia management. Training requirements are met prior to staff providing services to residents, annually, and as necessary based on the facility assessment. Based on the outcome of the facility assessment, additional training may include substance abuse. II. Record review Staff training records related to behavior management, dementia and substance abuse were requested from RDCS #1 on 3/7/24 at 10:46 a.m. -RDCS #1 said she was unable to find any documentation indicating the facility had provided the staff with training for behaviors, substance abuse or dementia. The Facility Assessment, last reviewed 3/1/24 (during the survey), was received from the NHA on 3/6/24 at 8:45 a.m. -The facility assessment did not identify substance abuse as part of the resident population served, despite the multiple residents with known current or history of substance abuse (cross-reference F838 for failure to complete a comprehensive facility assessment). III. Interviews A frequent visitor (FV) was interviewed on 3/4/24 2:38 p.m. The frequent visitor said there had been a large influx of admissions for residents with mental health diagnoses with behaviors and substance abuse diagnoses but the staff had not been offered any training in how to work with the residents. The social services director (SSD) was interviewed on 3/5/24 at 11:00 a.m. The SSD said the facility had been accepting an increased number of residents with behaviors and substance abuse issues in the last few months. He said the facility had not provided any education on mental health care and behaviors or substance abuse to the staff. He said he would have thought the facility would have provided training on behavior management and things to look for and do for substance abuse but no training had been offered. The restorative nurse aide (RNA) was interviewed on 3/7/24 at 1:00 p.m. The RNA said there had been an increase in admissions of residents who had mental health conditions and behaviors but no training had been provided to him or the other staff.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include: I. Cross-reference citations Cross-reference F689: The facility failed to ensure resident safety with accident hazards. The facility failed to ensure residents were assessed accurately and interventions were in place to prevent further elopements after two residents eloped, resulting in one resident sustaining a fracture. The facility's failure to protect residents from accident hazards created an immediate jeopardy (IJ) situation. Additionally, the facility failed to ensure residents were assessed timely for smoking safety and provided smoking assistive devices. Furthermore, the facility failed to keep chemicals and used razors secured safely. Cross-reference F600: The facility failed to prevent abuse resulting in actual harm. Cross reference F697: The facility failed to manage residents' pain resulting in actual harm. Cross-reference F607: The facility failed to notify staff of their right to be free of retaliation for reporting abuse. Cross-reference F609: The facility failed to report allegations of abuse to officials including the State Survey Agency. Cross-reference F610: The facility failed to thoroughly investigate allegations of resident verbal and physical abuse. Cross-reference F760: The facility failed to prevent significant medication errors. Cross-reference F835: The facility failed to provide adequate administration and follow up through action and inaction. Cross-reference F838: The facility failed to ensure an accurate and complete facility assessment was completed to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Cross reference F940: The facility failed to ensure all staff received training to care for the resident population including dementia care, substance abuse and mental health. Cross reference F947: The facility failed to ensure nurse aides had 12 hours of education annually based on their date of hire and annual performance review. II. Facility policy and procedure The QAPI policy was requested from the NHA on 3/6/24 at 2:12 p.m. -The policy was not received by the end of the survey on 3/7/24. III. Repeat deficiencies Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies. F689 for Accident hazards During a recertification survey on 4/19/22, F689 was cited at a D level scope and severity, a potential for more than minimal harm, isolated. During an abbreviated survey on 3/23/23, F689 was cited at a G level scope and severity, actual harm. During a recertification survey on 6/15/23, F689 was cited at an E level scope and severity, a potential for more than minimal harm, pattern. During an abbreviated survey on 11/20/23, F689 was cited at a D level scope and severity, a potential for more than minimal harm, isolated. During an abbreviated survey on 3/7/24, cited at a J level scope and severity, immediate jeopardy to resident health and safety, isolated. F697 Pain management During a recertification survey on 6/15/23, F697 was cited at an E level scope and severity, a potential for more than minimal harm, pattern. During an abbreviated survey on 3/7/24, F697 was cited at a G level scope and severity, actual harm. F838 Facility assessment During a recertification survey on 4/19/22, F838 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. During an abbreviated survey on 3/7/24, F838 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. F835 Administration During a recertification survey on 4/19/22, F835 was cited at a G level scope and severity, actual harm. During an abbreviated survey on 3/7/24, F835 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. F867 QAPI During a recertification survey on 6/15/23, F867 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. During a recertification survey on 4/19/22, F867 was cited at a G level scope and severity, actual harm. During an abbreviated survey on 3/7/24, F867 was cited at a F level scope and severity, a potential for more than minimal harm, widespread. IV. Interviews The nursing home administrator (NHA) and the director of nursing (DON) were interviewed together on 3/6/24 at 2:12 p.m. The NHA said the elopements were discussed at QAPI, but not in enough detail to identify and correct all of the issues such as Resident #2 removing her wanderguard. The NHA said she was not aware the smoking assessments had not been completed timely and smoking assistive devices were not provided. She said they started accepting residents who smoked a few months ago but the QAPI committee had not reviewed what the smoking program would entail. The NHA said the multiple missed medications and unavailability of medications was not identified or reviewed at QAPI. The NHA said the abuse investigations needed to be more thorough, however, she said that was not identified or reviewed at the QAPI meetings. The medical director (MD) was interviewed on 3/11/24 at 11:44 a.m. The MD said he thought the QAPI committee talked briefly, on 2/22/24, about the elopements that had occurred on 2/19/24. The MD said he did not realize the facility was now accepting residents who smoked. He said the facility had been a smoke free facility and he had not been informed of the change. The MD said he had not been advised of the multiple abuse allegations and altercations that had occured in the last two months. He said he should have been notified and the abuse should have been reviewed at QAPI. The MD said he was not aware the facility was having issues obtaining medications timely for residents resulting in missed doses. He said this should have been discussed at QAPI. The MD was not aware the facility had not done training on substance abuse or dementia care despite the increased admission of residents with those diagnoses.

Based on observation, record review and interviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility failed to: -Post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse; and, -Include protection for employees against retaliation for reporting in its abuse policy. Findings include: I. Professional reference According to the Elder Justice Act notice, undated, retrieved online 3/11/24 from https://lms.healthcareacademy.com/courses/HCA_Annual/ElderJusticeAct1d/EJA_poster.pdf: The Elder Justice Act (the Act) is a federal law passed as part of the Patient Protection and Affordable Care Act. Its aim is to combat abuse, neglect and exploitation of elders by promoting the discovery of crimes against residents of long term care facilities. It does this by requiring that specific individuals report any reasonable suspicion of a crime against anyone who is a resident of, or is receiving care from, a long term care facility. A long term care facility may not retaliate against an employee for making a report, or for causing a report to be made. This means that a facility may not discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done the employee; or file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee. II. Observation The facility was observed on 3/7/24 at 11:43 a.m. for signage regarding employees' right to non-retaliation. This signage was not found in the facility. II. Record review The Abuse and Neglect policy, revised March 2018, was provided by the regional director of clinical services (RDCS) #1 on 3/7/24 at 10:55 a.m. -The policy did not address retaliation for reporting abuse or neglect. III. Staff interviews The director of nursing (DON) was interviewed on 3/7/24 at 12:37 p.m. The DON said she did not know where the notice was posted that indicated the facility would not retaliate against employees for reporting abuse. She said a notice against retaliation should have been posted. Certified nurse aide (CNA) #8 was interviewed on 3/7/24 at 3:00 p.m. CNA #8 said she had never seen signage that notified staff of their right to be free from retaliation for reporting abuse.

Based on interviews and record review, the facility failed to ensure one (#1) of two residents reviewed for accidents out of four sample residents received adequate supervision to prevent an accident/hazard. Resident #1, who had a diagnosis of medically complex conditions, was admitted to the facility on [DATE]. The facility failed to follow standards of practice in providing incontinence care by not having all supplies ready and letting go of the resident after rolling her to her side. The facility failed to timely implement appropriate interventions, including assistance with all activities of daily living (ADL) as documented in her significant change 11/17/22 minimum data set (MDS) assessment. The facility failed to provide and implement two person bed mobility/toileting assistance and failed to consistently provide two person bed mobility/toileting assistance after the fall according to record review, interviews and in accordance with the resident's care plan. Due to the facility's failures, and the staff's failure to take proper and reasonable care when providing bed mobility/toileting assistance resulted in a fall from the bed that resulted in the resident sustaining injuries of a right and left femur (thigh) fractures, a right head laceration requiring seven staples, and required hospitalization for three days. Findings include: I. Facility policy and procedure The Falls Practice Guide policy, dated December 2011, was provided by the nursing home administrator (NHA) on 3/23/23 at 3:50 p.m. It read in pertinent part, The purpose of the Falls Practice Guide is to describe the process steps for identification of patient fall risk factors and interventions and systems that may be used to manage falls. Comprehensive care plan: Based upon the findings of the MDS (minimum data set) and CAAs (care area assessment) and following review of risk factors, environmental factors and other clinical conditions, the patient's initial care plan is updated or a comprehensive care plan is developed to include individualized patient interventions that focus on the patient's risk factors. II. Resident status Resident #1, age 89, was admitted initially on 1/29/19, and readmitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included left femur fracture, right femur fracture, muscle weakness, and anxiety disorder. The significant change 11/17/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene. Transfers did not occur over the entire seven day period. There were no behavioral symptoms or rejection of care. The significant change 1/25/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance with two persons physical assistance for bed mobility, transfers, dressing, toilet use, bathing and personal hygiene. There were no behavioral symptoms or rejection of care. The resident was always incontinent of bowel and bladder. III. Resident interview Resident #1 was interviewed on 3/21/23 at 11:39 a.m. She said certified nurse aide (CNA) #1 was going to change her and she rolled her to the side. Resident #1 said she was in a position that made her slip out of the bed and she fell to the wood floor. Resident #1 said she was in a state of shock and the police came and helped to calm her on the floor. Resident #1 said she was moved from the floor and put on a stretcher; she felt shocked, scared and stunned. Resident #1 said she felt numb at first and she did not feel like screaming when it happened. Resident #1 said she started feeling the pain on the way to the hospital. Resident #1 said now she had two people to change her, before the fall she had one person help with bed mobility. Resident #1 said her legs hurt now if she moved them and there was a large black scab on the top/back of her head. Resident #1 said there were certain places on her body that were still tender and she still had a fear of falling. IV. Record review Care plan: Review of the ADL care plan established prior to the 1/17/23 fall revealed that it had not been developed to include two persons physical assistance for bed mobility, dressing, toilet use, bathing and personal hygiene although the 11/17/22 MDS had been coded as requiring such care, which was the highest level of care needed during the seven day period. The ADL care plan was updated after the 1/17/23 fall and added two assist with bed mobility, toileting, daily hygiene, dressing, date initiated 2/13/23. -The resident had returned to the facility on [DATE], after her hospitalization . The care plan was not updated and revised to include two person assistance with bed mobility until 2/13/23, 28 days after the resident's fall on 1/17/23. Review of the urinary incontinence care plan revealed it was updated and added after the 1/17/23 fall two person assist during incontinence care date initiated 1/19/23. Review of Resident #1's medical record (EMR) revealed the following progress notes documented in pertinent part: 1/17/23 at 2:45 p.m., Registered nurse (RN) assessment: This nurse was called to resident's room by staff nurse stating resident had fallen out of bed while being changed by certified nursing aide (CNA). Upon entering the room noted resident laying on the floor faced down with a towel under her face. Bleeding noted from gash on the right side of resident's head. Had a small skin tear to right shoulder. Resident was able to state her name and state she was in pain and wanted to get off the floor. Another RN obtaining vital signs at this time. Clear area around resident for safety. While RN applied gauze to gash in head for pressure this nurse, head neck in alignment with assistance of CNA to turn resident over. Upon turning resident over noted a skin tear to resident right knee and right foot. Resident was still alert and oriented upon assessment. EMS (emergency medical services) arrives to take over. Fall protocol in place. 1/17/23 at 3:31 p.m., CNA was turning resident and rolled her over and let go for just a second and she rolled off the bed. The bed was in the high position. Resident was laying on her right side on her stomach. Called RN #1 and RN #2 to come assist. Call to 911 was placed and paramedics with (name) came at once. This writer called the daughter of resident and left her message of what was happening with her mother. Call and message was also left with RN at (provider) to inform medical doctor (MD) #1 and nurse practitioner (NP) #1. Resident received a laceration to right side of her (head) also scraped her knees and tore scabs off as well off her toes. She also had marks to her upper back and mid back on right side. Paramedics here and took at 3:25 p.m. 1/17/23 at 3:39 p.m., This RN responded to resident's reported fall while LPN (licensed practical nurse) called 911. Resident observed to be lying on the floor with a bleeding laceration to her head. The resident and CNA both reported that the resident fell while being turned in bed. Initial assessment showed that resident's vital signs were within her baseline limits (pulse 85, O2 (oxygen saturation) 90, BP (blood pressure) 143/93). A/O (alert and oriented) x4. Resident reported 10/10 pain, generalized, on her buttocks, and on her head. Tenderness to palpation in bilateral pelvic area. PERRLA (pupils equal, round, reactive to light and accommodation). Resident had a laceration to the right side of her head. Scabs on bilateral knees and toes opened during the fall and were bleeding. New small open area on buttocks resulting from the fall. Abrasions on the right shoulder and mid-back were also observed. EMT's arrived and took over resident care and transfer. 1/18/23 at 10:06 a.m.,IDT (interdisciplinary team) met to review fall from bed yesterday, remains in hospital. Was sent to hospital and remains there. Will review when returns. 1/19/23 at 1:17 p.m., Resident readmitted to the facility from community hospital via stretcher with (name) at 11:15 a.m. following post fall with diagnosis of bilateral femur fractures. Medication regimen reviewed with physician assistant (PA) #1, no issues found. Resident was A & O (alert and oriented) x3 (person, place and time), able to make her needs known. Resident was on a regular diet, regular texture, poor appetite, and eats meals by herself with a setup tray. Incontinence with bowel and bladder. Resident was on 2 L (liters) O2 (oxygen) via NC (nasal cannula). Dressing was changed on the bilateral lower leg today as per a report given by hospital RN. Resident had bruises on the back of bilateral hands and right forearm from the IV (intravenous) site. Resident was admitted to hospice at the hospital. Hospice admission nurse was in the building today to see the resident. Resident denies any pain at this time, states she was only in pain when her leg was moved. The resident had a new order for PRN (as needed) oxycodone. NP from optum informed about readmission and new order. Daughter updated about patient's condition and new order. Call light placed within reach. Bed was in the lowest position. V/S (vital signs) 120/54, 97.5, 63, 92% on 2L O2 via NC. 1/20/23 at 10:38 a.m., Update: Patient was sent out to hospital on 1/17/23 status post (s/p) fall with increased pain and laceration to right side of head. Pt was admitted to hospital where she was diagnosed with bilateral femur fractures. Pt was admitted to hospice services for end of life care. Patient readmitted to this facility on 1/19/23. Upon admission, per nursing note, patient with seven staples on right side of her scalp with crusted blood/OTA (open to air), bruise on back of both hands and RFA (right forearm) from IV site. Recent weight not available. Continue diet per order. Will restart supplements. 1/21/23 at 1:06 p.m., Resident continues on charting for readmission s/p fall. Resident had seven staples to head that are clean, dry and intact.Resident's bed in low position and requires the assistance of two persons to assist with changing. Resident had not complained of any pain or discomfort related to fall. Hospital records: The 1/17/23 emergency room physician note revealed in pertinent part, Reason for consult: Fall at nursing home. History of present illness: Resident #1 is an [AGE] year old female presenting with traumatic injuries sustained after falling at a skilled nursing facility. She was sent to the ED by medical transport for evaluation with her advanced directive documents and medication list. She was found to have bilateral distal femur fractures on plain film. Trauma surgery consultation was requested. Resident #1 was unable to provide history due to advanced dementia and was moaning in pain. Physical exam: Elderly female moaning in pain. Laceration right parietal (near the top of head) region. The 1/18/23 hospitalist progress note revealed in pertinent part, Assessment and Plan: This is an [AGE] year old female with a history of chronic lymphedema with chronic venous stasis ulcerations and wounds presenting to the emergency department after a fall during transfer resulting in bilateral distal femoral fractures. Toe abrasion; closed head injury; mechanical fall-laceration clean, dry, repaired in ED (emergency department), trauma surgery following. Mental status: She was disoriented. Psychiatric: comments: Moaning in pain. Review of the bed mobility task support provided for the past 30 days documentation revealed the following: -2/22/23 at 5:02 p.m. one person physical assistance was provided. -2/22/23 at 10:08 p.m. one person physical assistance was provided. -2/24/23 at 1:51 p.m. one person physical assistance was provided. -2/25/23 at 1:59 p.m. one person physical assistance was provided. -2/26/23 at 1:59 p.m. one person physical assistance was provided. -2/27/23 at 1:24 p.m. one person physical assistance was provided. -3/1/23 at 1:59 p.m. one person physical assistance was provided. -3/5/23 at 1:09 a.m. one person physical assistance was provided. -3/5/23 at 1:40 p.m. one person physical assistance was provided. -3/6/23 at 5:53 a.m. one person physical assistance was provided. -3/6/23 at 4:45 p.m. one person physical assistance was provided. -3/8/23 at 1:59 p.m. on person physical assistance was provided. -3/9/23 at 1:36 p.m. one person physical assistance was provided. -3/10/23 at 6:45 p.m. one person physical assistance was provided. -3/13/23 at 12:42 a.m. one person physical assistance was provided. -3/13/23 at 1:59 p.m. one person physical assistance was provided. -3/17/23 at 1:59 p.m. one person physical assistance was provided. -3/18/23 at 2:41 p.m. one person physical assistance was provided. -3/22/23 at 2:38 a.m. one person physical assistance was provided. -3/23/23 at 4:15 a.m. one person physical assistance was provided. -Although the newly revised care plan read, two assist with bed mobility updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. Review of the toileting task support provided for the past 30 days documentation revealed the following. -2/20/23 at 5:16 p.m. one person physical assistance was provided. -2/22/23 at 8:17 p.m. one person physical assistance was provided. -2/24/23 at 6:28 p.m. one person physical assistance was provided. -3/3/23 at 11:40 a.m. one person physical assistance was provided. -3/5/23 at 1:18 a.m. one person physical assistance was provided. -3/9/23 at 1:36 p.m. one person physical assistance was provided. -3/10/23 at 11:37 p.m. one person physical assistance was provided. -3/18/23 at 2:59 a.m. one person physical assistance was provided. -3/18/23 at 1:26 p.m. one person physical assistance was provided. -3/18/23 at 2:42 p.m. one person physical assistance was provided. -Although the newly revised care plan read, two person assist during incontinence care updated after Resident #1's fall, the staff continued to provide one person assistance, placing Resident #1 at a continued risk of another fall. V. Facility's investigation of Resident #1's fall The post fall investigation noted, Incident report: date of incident 1/17/23 at 3:00 p.m. Location: resident's room. Description of incident: CNA #1 was turning to change her and she rolled her over too far and she fell off the bed which was in the high position. Describe care provided to the patient following incident: CNA #1 was turning the resident and rolled her over and let her go for just a second and she rolled off the bed. The bed was in a high position. Resident was laying on her right side on her stomach. RN #1 and RN #2 were called to come assist. Call to 911 was placed and paramedics came at once. The resident's daughter was called and a message was left of what was happening with her mother. Call and message the physician. Resident received a laceration to the right side of head, scraped her knees and tore scabs off her toes. She had marks on her upper back and mid back on right side. Paramedics arrived and took at 3:25 p.m. Patient was taken to the hospital 1/17/23 at 3:35 p.m. Summary of alleged incident: CNA #1 was turning resident to change her, and she rolled her over too far and she fell off the bed which was in the high position. Disposition by NHA: After a thorough investigation, neglect was unsubstantiated. It was determined that the CNA followed the patient's care plan/task list related to ADL cares. Employee (CNA #1) was brought back from suspension. Patient returned from the hospital on 1/19/23 with bilateral fractures to the femur. Care plan was reviewed and updated to two-person assistance related to bed positioning/mobility and ADL cares due to change in resident condition. Education was initiated with CNAs related to positioning, fall prevention and reviewing tasks lists prior to caring for a patient. An audit was put into place to monitor the position of patients when providing cares and monitoring correct transfer status. This will be monitored weekly for 4 weeks. Statements: Resident #1 on 1/19/23 at 11:30 a.m. I have never felt abused or neglected by CNA #1. I am absolutely certain, I love that gal. It wasn't her fault. She's one of my best friends. I know how to report abuse or neglect. Multiple residents interviewed and all had no problems with CNA #1. CNA #1 on 1/17/23 and 1/18/23 (time not documented), the person conducting the interview was the NHA. Around 2:20 pm I went to the room to perform vitals. At this time, she (Resident #1) requested to be changed. I started cares. She (Resident #1) was rolled onto her left side, per patient request and care plan. I let go of the patient to turn to grab her brief on the side of me, at this time the patient started to roll off the bed. I tried to catch her but was unsuccessful. I immediately notified my nurse for assistance. Multiple staff members interviewed and all had no problems with CNA #1. RN #2 on 1/30/23 (time not documented), LPN #1 notified her of the fall. She instructed LPN #1 to call 911 while RN #1 and she assessed and stabilized the resident. VI. Staff interviews The NHA was interviewed on 3/23/23 at 2:00 p.m. She said CNA #1 was not suspended until 1/20/23 (the fall occurred 1/17/23) as they were not aware of the extent of Resident #1's injuries until later and as they got into the investigation for the fall it was determined there could be a suspicion of neglect so that was when they suspended her for three days (1/20/23, 1/21/23, and 1/22/23). The NHA said she was the abuse coordinator, but it was collaborative with the IDT. The NHA said after the fall they met as a team and put in three corrective plans-staff education, a skills fair with hand on return demonstration, and monitoring/auditing. The NHA said she addressed having the MDS assessment match the care plan to make sure it matched the required assistance levels. She said the team was monitoring staff to see if they were transferring according to the kardex (brief overview of individual patient care). The NHA said prior to the fall the MDS assessment did not match the care plan and the kardex but that was how she wanted it completed now. The NHA said if the MDS assessment said a resident needed two person assistance then it needed to be two person assistance on the care plan. The NHA said a CNA could not change how much assistance a resident needs. She said if the kardex said the resident needed two person assistance then that's what should be given. The NHA said it was important for CNAs to document correctly the level of assistance given to a resident in order to follow the proper transfer status, and important for safety of the patient and staff. The NHA said she would start immediate education on proper documentation and monitoring of incontinence care and bed mobility since it was brought to her attention, during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. CNA #1 was interviewed on 3/23/23 at 2:39 p.m. She said she went to change Resident #1 and she was rolled to her side, and when she got the brief, Resident #1 fell off the bed. CNA #1 said Resident #1 was panicky and upset and thought she was going to die. CNA #1 said Resident #1 was in a lot of pain when the paramedics picked her up, she was crying, moaning in pain and scared. CNA #1 said the bed was too high, her mattress was too small in width, and Resident #2 should have been a two person assist with bed mobility and incontinence care. CNA #1 said her usual incontinence care techniques were to get everything ready, roll the resident over, clean them, and put on a new brief. CNA #1 said she failed to have all of her supplies ready and she just got herself out of order and she let go of the resident and just was not thinking. CNA #1 said mainly Resident #1 should have been a two person assistance. RN #2 was interviewed on 3/23/23 at 2:50 p.m. She said she was the facility's infection preventionist and nurse educator. She said since Resident #1's fall she had been conducting audits related to transfers (but not specifically to bed mobility and toileting). RN #2 said the questions on the audit read, Did staff follow the care plan related to transfers? Residents positioned safely in bed during and after transfer? Staff able to verbalize the correct transfer status and position? RN #2 said the audits came after Resident #1's fall and was designed to capture bed mobility and transfer status. RN #2 said she was now doing the audit one time per month. RN #2 said since it was brought to her attention, during the survey, that staff were not following the care plan related to bed mobility and incontinence care and were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1, she would now rewrite the audit and redo the education. The MDS coordinator (MDS #1) and director of nursing (DON) were interviewed on 3/23/23 at 12:48 p.m. MDS #1 said she did a quarterly MDS assessment every three months, and annual MDS assessment (every 365 days). MDS #1 said if there was a significant change MDS assessment then that was a new starting date and it included a full assessment. MDS #1 said the full MDS assessments trigger the care plan to be updated and different departments contribute to the care plan. MDS #1 said she did the ADL, continence and falls sections of the assessment. MDS #1 said she decided what went to the kardex and she hand made the kardex from the care plan. MDS #1 said Resident #1's 11/17/22 MDS assessment was the last full assessment before the fall on 1/17/23 and that was the MDS assessment her care plan came from. MDS #1 said the 11/17/22 MDS assessment read that Resident #1's bed mobility was extensive assistance with two persons but that was not what she had put on the care plan, but with the audits she would start doing that now. MDS #1 said she would now put residents who required two person assistance on the MDS assessment with two person assistance on the care plan. MDS #1 said before the fall if the MDS assessment said the resident required two person assistance she would not put that on the care plan. MDS #1 said she had put down care in pairs on the care plan for Resident #1. MDS #1 said she did not put it on the care plan prior because a resident often would need one person assistance usually with occasional two persons assistance. MDS #1 and the DON said that Resident #1 should have two person assistance at all times for bed mobility and incontinence care, it was now on the resident's care plan and on the kardex. The MDS #1 and DON said it was important to follow for the resident's safety and health. MDS #1 and the DON said they would find out which CNAs were not providing two person assistance and write them up, since it was brought to their attention during the survey, that currently CNAs were documenting one person assistance with bed mobility and incontinence care on residents who required two person assistance including Resident #1. MDS #1 and the DON said it was important to have accurate documentation for best resident care and safety. CNA #2 was interviewed on 3/23/23 at 3:45 p.m. She said her process for incontinence care for a resident in bed was to first sanitize hands, get a brief, peri care spray and other supplies. She cleaned the resident in the front first, then rolled them to the side and held the resident while cleaning the backside. CNA #2 said after completion of incontinence care, she put a brief under the resident and centered it and rolled the resident onto their back and pulled the brief up and tabs it, checking to make sure it was straight. CNA #3 was interviewed on 3/23/23 at 3:53 p.m. She said staff should round every two hours to check on the residents. She said her process for incontinence care was to first close the door or curtain, sanitize hands, get supplies ready such as brief, wipe, and peri spray. CNA #3 said she would tell the resident what she was going to do, wipe the front first, then roll resident to the side holding them, and pull out the old brief, put on a new brief, and roll to the middle to get them situated and connect tabs, then roll to the other side to straighten brief. The DON was interviewed on 3/23/23 at 4:06 p.m. She said when staff provided incontinence care they were to first knock, tell the resident why they were there. She said they should gather equipment and supplies such as wipes, and a brief. She said the staff then provided peri-care and undo one side of the brief and tuck under, roll back and pull the dirty brief out and pull the new brief up and reposition. The DON said the staff should be touching and holding the resident when they were rolled. The DON said what went wrong with Resident #1 during incontinence care and the fall on 1/17/23 was CNA #1 reached for something and let go of Resident #1 and because the bed was positioned so high it led to an injury. The DON said it was important for resident safety for the staff to know how to provide proper incontinence care.

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 and to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases and infections. Record review revealed the facility has been in outbreak status since late December 2021. Specifically, the facility was in outbreak status as of 12/23/21 when a staff member tested positive for COVID-19. On 12/27/21, another staff member tested positive for COVID-19. Thereafter, the following staff tested positive for COVID: one positive staff member (1/3/22), two positive staff members (1/11/22), one positive staff member (1/14/22), one positive staff member (1/20/22), two positive staff members (1/21/22), one positive staff member (2/15/22), one positive staff member (2/16/22), one positive staff member (3/8/22), one positive staff member (3/21/22), two positive staff members (3/22/22), two positive staff members (3/25/22), one positive member (3/29/22), one positive staff member (4/3/22), and one positive staff member (4/5/22). The current line listing on 4/6/22, showed 13 residents had tested positive for COVID-19. Results from the 4/8/22 tests showed two residents were positive. Results from the 4/12/22 test results included an additional five residents were positive. Results from the 4/18/22 revealed another three residents testing positive. Observations, record review and staff interviews, from 4/6/22 through 4/19/22, revealed multiple and repeated failures in the facility's infection control program. This created an immediate jeopardy situation with the likelihood of serious harm due to the potential for further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff, and others, if not corrected immediately. Specifically: -The facility failed to follow the Center for Medicare and Medicaid Services (CMS) outbreak testing guidance, beginning on 12/23/21, to routinely test staff bi-weekly while in outbreak status, creating a situation for the transmission of highly infectious COVID-19. Cross-reference F886L. -The facility failed to ensure staff properly wore personal protective equipment (PPE) throughout the facility and when caring for residents in isolation rooms. -The facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. -The facility failed to ensure equipment was sanitized between residents and dining room tables were cleaned properly prior to the next meal. -The facility failed to ensure resident rooms were properly cleaned. Cross-reference F886 and F888. Findings include: I. The facility's COVID-19 status On 4/6/22, upon entry into the facility, the facility had the following confirmed positive cases of COVID-19: 13 residents in isolation; four residents in isolation who were roommates of residents who had tested positive; and nine positive staff members since 3/8/22. II. Immediate Jeopardy A. Findings of Immediate Jeopardy Record review revealed the facility has been in outbreak status since late December 2021. Specifically, the facility was in outbreak status as of 12/23/21 when a staff member tested positive for COVID-19. On 12/27/21, another staff member tested positive for COVID-19. Thereafter, the following staff tested positive for COVID: one positive staff member (1/3/22), two positive staff members (1/11/22), one positive staff member (1/14/22), one positive staff member (1/20/22), two positive staff members (1/21/22), one positive staff member (2/15/22), one positive staff member (2/16/22), one positive staff member (3/8/22), one positive staff member (3/21/22), two positive staff members (3/22/22), two positive staff members (3/25/22), one positive member (3/29/22), one positive staff member (4/3/22), and one positive staff member (4/5/22). The facility has had the following number of COVID positive residents since January 2022. Specifically, COVID positive residents were identified as follows: three residents (1/11/22), one resident (1/11/22), one resident (3/11/22), two residents (3/15/22), two residents (3/18/22), four residents (3/22/22), one resident (3/23/22), four residents (3/25/22), one resident (3/29/22), one resident (3/31/22), one resident (4/1/22), one resident (4/2/22), three residents (4/5/22), and two residents (4/8/22). Thereafter, during the survey, there were five residents positive on 4/12/22 and another three residents on 4/18/22. Observations, record review and staff interviews, from 4/6/22 through 4/19/22, revealed multiple and repeated failures in the facility's infection control program, including the facility's failure to follow outbreak testing guidance, failure to properly and appropriately use PPE and perform staff and resident hand hygiene, failure to clean equipment and sanitize the dining room tables using proper technique, and failure to properly clean resident rooms. The above failures in the facility's infection control program created an immediate jeopardy situation with the likelihood of serious harm and the potential for further transmission of the highly infectious COVID-19 virus to residents throughout the facility, staff, and others, if not corrected immediately. B. Facility notice of immediate jeopardy On 4/12/22 at 7:43 p.m. the nursing home administrator (NHA) was notified that the failures identified above in infection control created an immediate jeopardy situation that placed all residents in the facility at risk for serious harm (COVID-19). C. Facility plan to remove immediate jeopardy On 4/14/22 p.m. the NHA provided a plan to remove the immediate jeopardy. The plan read: Observations and monitoring of PPE usage (which included N95 respirator masks, eye protection, gowns and gloves) and handwashing was conducted by members of the interdisciplinary team (department managers) during the overnight shift on 4/12/22. On 4/12/22, the door code was changed by the maintenance director on the service hall door and a sign posted for all staff to enter the facility through the front door of the facility only to ensure screening is being conducted for every staff member prior to starting their shift and entering resident areas. The screening will be conducted by the supervisor on duty or receptionist and will ensure each staff member has donned an N95 respirator mask and eye protection prior to entering a resident area. All resident equipment was disinfected with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant on 4/12/22 by the interdisciplinary team (department managers). All dining tables were disinfected with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant on 4/12/22 by the interdisciplinary team. Housekeeping Supervisor or designee will observe for proper cleaning of the dining room tables after each meal, every shift. Housekeeping Supervisor or designee will monitor through audits the observation completed for proper cleaning of the dining room tables after each meal, every shift. Education with return demonstration was completed on 4/12/22 to 52 out of 71 total facility staff members regarding the facility policies and procedures for PPE use, including the requirement for N95 respirator masks and eye protection to be worn in all resident areas, the procedures for the donning and doffing of PPE, discarding single-use gowns after each use, sanitization of eye protection, proper handwashing procedures, equipment sanitization in between resident use, and providing residents with hand hygiene prior to meals. All staff will complete the education with return demonstration prior to the start of their next scheduled shift. The director of nursing and/or designee will track and monitor each staff member who has received or not yet received the training to ensure compliance. Education was started on 4/12/22 with the housekeeping staff regarding the disinfecting of dining room tables after each meal, performing hand hygiene in between resident rooms when delivering linen and personal laundry and performing hand hygiene prior to donning and after doffing gloves. Education will be provided to new staff during orientation. The education for all the housekeeping staff will be completed by 4/13/22. The director of nursing and/or designee will monitor facility staff for infection control practices 3 times every shift and on the spot education with return demonstration will be provided upon a negative observation. The interdisciplinary team to include the medical director will conduct a root cause analysis to determine the progress of the corrective action and will provide a report to the quality performance improvement committee to discuss recommendations and additional C. Removal of immediate jeopardy On 4/14/22 at 1:00 p.m. the NHA was notified that the immediate jeopardy was lifted based on the facility's plan to address the immediate jeopardy (see above). However, deficient practice remained at F level, widespread with the potential for more than minimal harm. II. Failure to maintain an effective infection prevention and control program A. The facility failed to follow CMS and CDC outbreak testing guidance, as well as the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, to routinely test all staff bi-weekly, creating a situation for the transmission of highly infectious COVID-19. Cross-reference F886. Professional reference: Consistent with CMS and CDC testing guidance, the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, read: When one or more positive tests are identified in a resident or health care professional (HCP) (regardless of vaccination status), the facility moves to outbreak testing and following additional response measures outlined below. -Asymptomatic HCP (including ancillary non-medical services providers) and residents who are up to date with all recommended COVID-19 vaccine doses should test twice weekly for [CONDITION(S)]-CoV-2 using a lab-based PCR test. If HCP work infrequently at the facility, the lab-based PCR test should be performed within three days before their shift. -A HCP who tests positive, regardless of vaccination status, should be excluded from work and instructed to isolate at home. HCP should self-report positive results to any additional employer so that disease control measures can be implemented if necessary. Contrary to the above testing guidance, the facility failed to test all staff following notification of an outbreak as of 12/23/21. Specifically: -A line list, dated 4/12/22, was provided by the consultant director of nursing (DON) on 4/12/22 at 3:15 p.m. It documented that only 18 staff members had been tested for COVID-19 that day (4/12/22), out of 72 total staff members who worked at the facility. -A line list for Friday, 4/8/22, documented 32 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC (point of care) tested (alternative testing that does not require sending the test to the lab) until the next testing date on 4/12/22. -A line list for Tuesday, 4/5/22, documented 22 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC tested until the next testing date on 4/8/22. The facility was unable to provide documentation that the staff members who were not tested had been contacted, provided education, been removed from the schedule, or had disciplinary action to ensure compliance with the testing requirements. Moreover, the facility failed to ensure staff were conducting self-testing in accordance with testing guidelines and in a manner to prevent the spread of infection. Observations showed staff members failed to swab their nose with five circular motions in each nostril to ensure the testing was effective and would produce an accurate result. Staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22, and 22 out of 70 staff were tested . Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation, a fourth resident had been placed in isolation after testing positive for COVID-19. B. The facility failed to ensure staff properly wore personal protective equipment (PPE) throughout the facility and when caring for residents in isolation rooms. And, the facility failed to ensure staff followed proper hand hygiene procedures for themselves and for the residents. On 4/12/22 at 10:40 a.m., CNA #3 was interviewed. He said he had been working at the facility for a month and the facility had been in outbreak status the entire time. He said he had not been told by nursing management at the facility to wear a N95 respirator mask or eye protection until the survey process started. He said he had worn a surgical mask since his first day at the facility. CNA #3 said he said he had observed housekeeping staff entering COVID-19 positive rooms and not donning any PPE. He said when he arrived in the morning, the night shift never wore any masks or eye protection. 1. Professional References and facility infection control manual PPE: CDC and CMS Guidance on PPE when COVID-19 has been identified in the building: The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated 2/2/22), retrieved on 4/22/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, read in pertinent part, HCP (health care provider) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 infection should adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved N95 or equivalent or higher-level respirator, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy. According to the CDC guidance, Use Personal Protective Equipment (PPE) When Caring for Patients with Confirmed or Suspected COVID-19, dated 2/2/22, retrieved on 4/22/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html: -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 facility infection control manual received on 4/6/22 from the NHA at a sister facility (NHA#1), read in pertinent part, If a center has the capability to accept a patient/resident who requires droplet/airborne transmission-based precautions and the patient/resident can be placed in a non-negative pressure room with the door kept closed with employees wearing at least an N95 fit tested respirator, as in the case of a suspected or confirmed case of COVID-19, the employees caring for the patient/resident are required to be fit tested for an N95 or equivalent respirator before entering the patient's/resident's room. The Strategies for Optimizing the Supply of Isolation Gowns (updated 1/21/21, retrieved on 4/27/22 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/isolation-gowns.html, Regarding Conventional Capacity Strategies, reads in pertinent part: In general, CDC does not recommend the use of more than one isolation gown at a time by HCP when providing care to patients with suspected or confirmed [CONDITION(S)]-CoV-2 infection. Use isolation gown alternatives that offer equivalent or higher protection. Nonsterile, disposable patient isolation gowns, which are used for routine patient care in healthcare settings, are appropriate for use by HCP when caring for patients with suspected or confirmed COVID-19. In times of gown shortages, surgical gowns should be prioritized for surgical and other sterile procedures . Once gown availability returns to normal, healthcare facilities should promptly resume conventional practices . The director of nursing from a sister facility (mobile DON) was interviewed on 4/12/22 at 4:47 p.m. The mobile DON said the facility was in conventional practice, which indicated they had no shortages of N 95 masks, surgical masks and gowns. Hand hygiene: The Centers for Disease Control (CDC) Hand Hygiene updated 1/30/2020, retrieved on 4/22/22 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. Practicing 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 [CONDITION(S)]-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(S)] or 70% isopropanol 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. The facility infection control manual received on 4/6/22 from the NHA at a sister facility (NHA#1), read in pertinent part, Standard precaution principles are designed to reduce the risk of transmitting microorganisms from both recognized unrecognized sources of infection in healthcare settings. Standard precautions are designed to protect both healthcare personnel and patients from contact with infectious agents. Standard precautions include: -Hand hygiene (handwashing with soap and water or use of an alcohol-based sanitizer) before and after patient contact and after contact with the immediate patient care environment. -Perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites, if necessary. -Wash hands or use alcohol-based hand sanitizer upon completion of patient contact and before caring for another patient -Perform hand hygiene before touching a patient, performing an invasive procedure or manipulating an invasive device. -Perform hand hygiene after contact with patient's intact or non-intact skin, after touching items or surfaces in the immediate care environment, even if you did not touch the patient. 2. Observations revealed staff failed to properly wear and dispose of PPE and perform hand hygiene to prevent the transmission of infectious COVID-19. a. Observations 4/6/22 - Hand hygiene failures (i) During a continuous observation on the 200 unit on 4/6/22 starting at 12:04 p.m. and ending at 12:44 p.m., the following was observed: -At 12:04 p.m. the lunch meal cart was delivered to the 200 unit nursing station. -At 12:16 p.m. CNA #3 opened the cart and started passing trays. He donned gloves and entered room [ROOM NUMBER]. He did not perform hand hygiene prior to donning the gloves. The CNA set up the resident's meal, asked her if she needed anything else and left the room. With the same gloved hands, he returned to the meal cart and picked up another tray for the same room. He entered the room and delivered the meal to the resident in bed B. He grabbed the bed controls and raised the head of the bed, then took the lids off the beverages and poured the beverages into a sippy cup. He set up her meal and left the room. He had not offered either resident in room [ROOM NUMBER] hand hygiene prior to the start of their meal. The CNA doffed his gloves, threw them into the trash, reached into his pocket, pulled out a new pair of gloves and donned the gloves. He did not perform hand hygiene prior to donning the gloves. The CNA returned to the meal cart, picked up another tray and entered room [ROOM NUMBER]. He delivered the meal tray to bed A. He placed the tray on the over bed table and left the room. He did not offer hand hygiene to the resident before leaving the room. He doffed his gloves, reached into his pocket and donned new gloves. He did not perform hand hygiene prior to donning the gloves. The CNA then entered room [ROOM NUMBER] and walked to bed B. He delivered the meal tray, took off the plate cover and the covers for the beverages. He did not offer the resident hand hygiene. He left the room and returned to the meal cart and picked up the meal tray for the resident in bed A. He placed the meal tray in front of the resident. He left the room, doffed his gloves, went to the nursing cart and took a handful of gloves and put them in his pocket. He donned a new pair of gloves. He did not perform hand hygiene prior to donning the gloves. -An unidentified CNA took a meal tray from the meal cart and entered room [ROOM NUMBER]. She did not offer the resident hand hygiene prior to the resident's meal. (ii) During a continuous observation on the 200 unit on 4/6/22 beginning at 12:15 p.m. and ending at 12:29 p.m., the following was observed: -CNA #2 delivered a meal tray to room [ROOM NUMBER], removed personal items from the bedside table, provided set-up meal assistance for the resident and upon exiting the room, she did not perform hand hygiene, but rather, went back to the food cart for another tray; -CNA #2 delivered two meal trays to bed A and B in room [ROOM NUMBER]. She did not perform hand hygiene upon exiting the room; and -CNA #2 put on a gown and gloves and entered room [ROOM NUMBER] to deliver the last meal tray. She did not sanitize her hands before donning her gloves. b. Observations 4/7/22 - Hand hygiene failures On 4/7/22 at 9:55 a.m. certified nurse aide (CNA) #4 failed to perform hand hygiene after doffing personal protective equipment (PPE) and upon leaving room [ROOM NUMBER], a Covid 19 isolation room. On 4/7/22 beginning at 9:45 a.m. and ending at 10:43 a.m., an unidentified CNA entered numerous resident rooms without performing hand hygiene before entering or after exiting. Observations were as follows: -The CNA entered room [ROOM NUMBER] and removed the resident's breakfast tray. No hand hygiene was performed before entering the room or after exiting. -The CNA entered room [ROOM NUMBER] with a pen and paper to obtain the resident's lunch order. No hand hygiene was performed before entering the room or after exiting. -The CNA then entered and exited room [ROOM NUMBER] quickly, without performing hand hygiene, and immediately entered room [ROOM NUMBER]. The CNA exited room [ROOM NUMBER] with the resident's meal tray and returned to the room to obtain the resident's lunch order. No hand hygiene was performed before entering the room or after exiting. -The CNA entered and exited room [ROOM NUMBER]. No hand hygiene was performed. -The CNA entered room [ROOM NUMBER] with vital sign equipment. No hand hygiene or cleaning of vital sign equipment was performed. -The CNA entered and exited room [ROOM NUMBER] without performing hand hygiene. -The same CNA entered room [ROOM NUMBER] with vital sign equipment. No hand hygiene was performed after exiting room [ROOM NUMBER]. -The CNA then entered room [ROOM NUMBER]. No hand hygiene was performed before entering or after exiting room [ROOM NUMBER]. c. Observations 4/10/22, 4/11/22 and 4/12/22 - PPE and hand hygiene failures (100, 200 and 400 units) On 4/10/22 at 11:34 p.m. CNA #9 was observed in a resident area on the 400 unit, in the hallway near resident rooms, without wearing eye protection. On 4/10/22 at 11:34 p.m., upon entering the 200 nursing station, registered nurse (RN) #4 was observed putting a surgical mask on her face. She was not wearing a N95 respirator mask or eye protection. She said she was aware the facility was in outbreak status. She then doffed the surgical mask and donned a N95 respirator mask and goggles. On 4/10/22 at 11:35 p.m., RN #4 was observed at the nurses' station on the 200 unit. Her surgical mask was below her nose and mouth. An unidentified CNA also was observed in the area, wearing a surgical mask below her nose which was changed to a N95 at 11:53 p.m. On 4/10/22 at 11:38 p.m. an unidentified nurse and an unidentified CNA were observed at the 100 unit nursing station without a mask and face shield. Upon prompting, they began to don a N95 respirator mask and a face shield. On 4/11/22 at 10:30 a.m., CNA #11 was observed sitting at the 400 unit nurses' desk. She was not wearing a face mask. She said she had just sat down and she had to get a drink of water. She said a break room was available to use when she needed to remove her mask, although she had not gone there to remove her mask. On 4/11/22 at 11:12 a.m., the maintenance director (MTD) was in his office across from the 400 unit nurses' station. He did not have his mask on and his door was wide open. Residents walked by his office. At 11:30 a.m., he continued to sit at his desk with his mask off. On 4/11/22 beginning at 11:25 a.m., licensed practical nurse ( LPN) #4 was observed passing medications and providing care to residents wearing a N95 mask with the straps cut off and covered with a cloth mask. On 4/11/22 at 1:15 p.m., an unidentified laundry worker was observed to enter resident rooms on the 400 unit without sanitizing prior to entering rooms and upon exit. She was touching the doors, and removing hangers and other laundry from the rooms. On 4/12/22 at 9:05 a.m. an unidentified housekeeper was observed in the hallway of the 100 hall. Her mask was below her nose and mouth. d. Observation 4/11 and 4/12/22 on the 200 unit - isolation rooms - PPE and hand hygiene failures. On 4/11/22 at 10:32 a.m., LPN #2 was observed entering room [ROOM NUMBER], an isolation room for COVID-19. She put on a gown, gloves, and booties. She then took off the gloves and put new gloves on without performing hand hygiene. She disposed of the gown, booties, and gloves in the room prior to exiting. However, she did not sanitize her face shield upon exiting the isolation room and returning to the nurses' station. On 4/11/22 at 10:43 a.m., LPN #2 was observed entering room [ROOM NUMBER], an isolation room for potential norovirus. She put on a gown, booties, and gloves. She disposed of the gown, booties, and gloves in the room prior to exiting. However, she again did not sanitize her face shield. She also did not perform hand hygiene upon exiting the room. She returned to the nurses' station to chart. On 4/11/22 at 10:45 a.m., CNA #8 was observed in room [ROOM NUMBER], an isolation room for presumptive COVID-19. She had a gown, gloves, N95 mask, and a face shield on. She was observed pulling down her mask to speak to the resident. On 4/11/22 at 10:57 a.m., an unidentified CNA was observed entering room [ROOM NUMBER], an isolation room for COVID-19. She put on gloves, a gown, then booties. She did not change gloves or perform hand hygiene after touching her shoes to put the booties on. On 4/11/22 at 11:11 a.m., CNA #8 was observed leaving room [ROOM NUMBER], an isolation room. She disposed of the gown and gloves in the room. She replaced her mask in the hallway. She did not perform hand hygiene after leaving the isolation room. On 4/11/22 at 11:49 a.m., the director of rehabilitation (DOR) was observed entering room [ROOM NUMBER], an isolation room for presumptive COVID-19. He put on a gown and gloves. He disposed of his gown and gloves inside the room. However, upon leaving the room, he did not sanitize his face shield or perform hand hygiene. On 4/11/22 at 12:18 p.m. CNA #8 was observed in room [ROOM NUMBER], an isolation room for COVID-19. Her PPE gown was not tied and was falling off her shoulders. Upon exiting the room, she hung her gown in the room and stated she would use it again. She left the room, without sanitizing her face shield or performing hand hygiene. -CNA #8 then picked up a tray for room [ROOM NUMBER], an isolation room for presumptive COVID-19. She entered the room and put on a used gown which she did not tie. The gown kept falling off while she was in the room. She did not put gloves on. She helped the resident set up the lunch tray, but did not encourage hand hygiene for the resident prior to eating. CNA #8 left her used gown in the room. She did not sanitize her face shield or perform hand hygiene upon leaving the room. On 4/11/22 at 12:25 p.m. LPN #2 put on a gown, booties, and gloves prior to entering room [ROOM NUMBER] which was an isolation room. Upon exiting the room, she disposed of the gown, booties, and gloves inside the room. She did not perform hand hygiene or sanitize her face shield upon exiting the room. On 4/11/22 at 2:18 p.m. CNA #8 entered COVID-19 isolation room [ROOM NUMBER] again, this time with a clipboard and pen. She put on the gown she had left hanging in the room earlier. She did not put on gloves. She held the clipboard and used the pen to take the resident's meal order. Thereafter, she exited the room, leaving the used gown hanging in the room. On 4/11/22 at 2:55 p.m. the resident in room [ROOM NUMBER], an isolation room for COVID-19, activated her call light. CNA #8 knocked and opened the door. She stood in the doorway and asked the resident what she needed. A used gown was hanging on the wall. The CNA then entered the room and put on the used gown which was on the wall. She took the resident's meal order. Upon exiting the room, she hung her gown back up in the room. She then realized she had not turned off the call light. She re-entered the room and put the used gown back on but did not don gloves. Upon exiting the room, she hung up the gown. She did not sanitize her face shield. On 4/12/22 at 9:24 a.m. a small trash can was observed outside room [ROOM NUMBER], an isolation room for COVID-19; it was overflowing with used PPE. On 4/12/22 at 9:34 a.m. LPN #4 was observed on the 200 unit in the hallways and entering resident rooms. While she was in the resident area, she was wearing a N95 mask with the straps cut off and covered with a cloth mask to hold the N95 in place. On 4/12/22 at 2:30 p.m. CNA #5 was observed wearing a N95 mask below her nose while sitting at the nurses' station near the 100 and 200 unit with residents in close proximity. On 4/12/22 at 7:54 p.m. LPN #5 was observed in the 200 hallway with her medication cart with a N95 mask on her chin, below her nose and mouth. On 4/12/22 at 7:59 p.m. CNA #7 was observed in room [ROOM NUMBER], an isolation for presumptive COVID-19. CNA #7 did not have a gown or gloves on. Her N95 mask was below her nose and mouth. On 4/12/22 at 8:01 p.m. an unidentified nurse was observed standing at the medication cart on the 300 unit. She was pulling medications out of the cart and checking the computer. She was not wearing a facial covering or eye protection. Upon prompting, she donned a N95 respirator mask and eye protection. Upon entering the 200 unit nursing station, LPN #3 and an unidentified CNA were observed sit

Based on observations, record review and interviews, the facility failed to test staff, including individuals providing services under arrangement for Coronavirus (COVID-19). Specifically, the facility had been in a COVID-19 outbreak status since 12/23/21 that included positive cases for both residents and staff. The facility failed to conduct bi weekly PCR testing for all staff per the CDC and CMS guidance due to outbreak status since 12/23/21, to ensure the virus did not spread to residents within the facility. The facility failed to protect individuals, equipment and supplies, allowing individual and testing items within six feet of the testing area and each other. Observations showed staff performing testing in front of the testing supplies, therefore not protecting the testing equipment from being contaminated. The testing area was shared by two individuals with the testing occurring within six feet of the individuals and their desk area. In addition, the facility failed to ensure staff were conducting self-testing in accordance with testing guidelines. Observations showed staff members failed to swab their nose with five circular motions in each nostril to ensure the testing was effective and would produce an accurate result. Nursing management, in the room during the testing process, failed to instruct and provide education to facility staff members who were testing themselves incorrectly. The facility staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22 and 22 out of 70 staff were tested . Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation, a fourth resident had been placed in isolation after testing positive for COVID-19. In addition, observations revealed numerous infection control breaches which led to the facility's failure to prevent the spread of COVID-19. Cross reference F880 (Infection control), F888 (COVID-19 vaccination), F835 (administration), F837 (governing body) and F867 (QAPI). Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy The facility had been in a COVID-19 outbreak status since 12/23/21 that included positive cases for both residents and staff. The facility failed to conduct bi weekly PCR testing for all staff per the CDC and CMS guidance due to outbreak status since 12/23/21, to ensure the virus did not spread to residents within the facility. The facility failed to protect individuals, equipment and supplies, allowing individuals and testing items within six feet of the testing area and each other. Observations showed staff performing testing in front of the testing supplies, therefore not protecting the testing equipment from being contaminated. The testing area was shared by two individuals with the testing occurring within six feet of the individuals and their desk area. The facility staff failed to complete appropriate hand hygiene during and after the testing process and staff interviews showed that not all staff were aware of the testing day and admitted to not completing a PCR test. The last PCR test results were on 4/8/22 and 22 out of 70 staff were tested . Ten staff were within the 90 days of testing positive for COVID-19 and the facility had two staff members with religious exemptions. As a result of testing, three residents tested positive for COVID-19 and upon observation at the facility, a fourth resident had been placed in isolation after testing positive for COVID-19. In addition, observations revealed numerous infection control breaches which led to the facility's failure to prevent the spread of COVID-19. Cross-reference F880 and F888. B. Imposition of immediate jeopardy On 4/12/22 at 7:43 p.m., the nursing home administrator (NHA) and the regional nursing consultant (RNC) were notified of the immediate jeopardy situation created by the facility's failure to conduct COVID-19 testing as directed by the state health department, CMS and CDC guidelines while in outbreak since 12/23/21. C. Facility plan to remove immediate jeopardy On 4/14/22 at 11:15 a.m. the facility submitted a plan to remove the immediate jeopardy. The plan to remove the immediacy read: 1. Corrective action COVID-19 POC rapid testing (point of care) was completed on 4/12/22 for 22 of 72 employees. All staff members who did not complete the mandatory testing were contacted and educated that they were not able to work their shift without completing the mandatory COVID-19 POC test. All staff will complete the COVID-19 testing prior to the start of their scheduled shift. The supervisor on duty or designee will check each staff member before the start of their shift to ensure they have been tested . The supervisor on duty will contact the director of nursing and administrator for permission to remove a staff member from the facility if they refuse to comply with the mandatory COVID-19 POC test. Employee COVID-19 PCR testing will occur on Tuesdays and Fridays in the front entrance conference room. Notices will be posted at the time clock, on the director of nursing's office door and the employee bulletin board. On Monday and Thursday, the day prior to the testing day, reminders will be sent to all staff by utilizing a text messaging system. The testing room was moved to the front entrance conference room on 4/14/22: the emergency door will be kept open during testing to provide ventilation, distancing of six feet or more will occur during the testing process, surfaces will be disinfected before, in between and after testing with Eco Lab's Peroxide Multi-Surface Cleaner disinfectant. Monitoring of testing will be completed on each testing day by the director of nursing or designee, dressed in full PPE. Education was provided to all staff on the proper testing procedures such as hand hygiene prior to and following the swab test and accepted swab techniques of five circular motions in each nostril. Education was completed on 4/12/22 and 4/13/22. Testing requirements and frequency will be based on CMS/CDC and local public health authority guidance. 2. Systemic changes Education will be provided to all new staff, including agency, on the testing day's procedures and requirements, to include the proper testing procedures such as, hand hygiene prior to and following the swab test and accepted swab techniques of five circular motions in each nostril. Education will be provided to the director of nursing and/or designee on ensuring unused testing supplies and other PPE/equipment is removed from the testing room, ensuring social distancing of six feet or more during employee testing, disinfecting testing surfaces before, in-between, and after employee testing, ensuring the emergency door in the office will remain open during testing for ventilation, and proper testing procedures are completed such as hand hygiene prior to and following the swab test and swab techniques of five circular motions in each nostril. Education will be completed on 4/12/22. The nursing home administrator or designee will monitor CDC testing requirements and public health recommendations and implement any new changes to ensure testing compliance. 3. Monitoring The director of nursing and/or designee will monitor employee testing twice per week to ensure all staff have been tested . If a staff member fails to be tested , the director of nursing will remove the employee from the schedule and discipline action will follow. The interdisciplinary team, which includes department managers, will have access to the lab results for COVID-19 testing to review both resident and staff COVID-19 test results. The team member assigned will be responsible to notify the nursing home administrator and the director of nursing to create a plan of action. Each team member will have lab result access on 4/18/22. The interdisciplinary team, to include the medical director, will conduct a root cause analysis to determine the progress of the corrective plan and will provide a report to the quality assurance performance improvement committee to discuss recommendations and additional corrective actions. D. Removal of the immediate jeopardy The NHA and DON were notified on 4/14/22 that the above plan was accepted on 4/14/22 at 12:54 p.m. and the immediate jeopardy was removed based on the facility's plan set forth above. However, deficient practice remained at F level, widespread with the potential for more than minimal harm. II. Facility policy and procedure The Obtaining Anterior Nasal Specimen, dated 2/21/22, was provided by the assistant nursing home administrator (ANHA) on 4/21/22 at 4:44 p.m. It revealed, in pertinent part, Procedure steps to conduct an anterior nasal specimen collection for COVID-19: -Perform hand hygiene. -DON required PPE in the following order: gown, N-95 mask, face shield or goggles and gloves. -To collect an anterior nasal specimen: remove the swab from the package, carefully insert the swab into the nostril, using gentle rotation, push the swab until resistance is met at the level of turbinates (approximately one centimeter or half an inch into the nostril), rotate the swab five time or more against the nasal wall, slowly remove the swab from the nostril, and using the same swab, repeat the process in the other nostril. -Process the swab in accordance with manufacturer recommendations. -Discard used testing materials in a biohazard container. -Remove and discard gloves. Perform hand hygiene. Don clean gloves for the next test. III. Professional reference Consistent with CMS and CDC testing guidance, the Residential Care Facility (RCF) Comprehensive Mitigation Guidance, revised on 4/8/22, documented: When one or more positive tests are identified in a resident or health care professional (HCP) (regardless of vaccination status), the facility moves to outbreak testing and following additional response measures outlined below. -Asymptomatic HCP (including ancillary non-medical services providers) and residents who are up to date with all recommended COVID-19 vaccine doses should test twice weekly for [CONDITION(S)]-CoV-2 using a lab-based PCR test. If HCP work infrequently at the facility, the lab-based PCR test should be performed within three days before their shift. -A HCP who tests positive, regardless of vaccination status, should be excluded from work and instructed to isolate at home. HCP should self-report positive results to any additional employer so that disease control measures can be implemented if necessary. IV. Failure to ensure all staff were tested for COVID-19 during an outbreak and failure to ensure staff were testing themselves in accordance with testing guidelines to achieve an accurate result. A. Record review A sign, undated, was posted on the director of nursing's (DON's) office door indicating COVID-19 testing was on Tuesdays and Fridays in the DON's office. It documented all staff were required to be tested by 2:00 p.m. A line list, dated 4/12/22, was provided by the consultant DON on 4/12/22 at 3:15 p.m. It documented that only 18 staff members had been tested for COVID-19, that day (4/12/22), out of 72 total staff members who worked at the facility. A line list for Friday, 4/8/22, documented 32 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC (point of care) tested (alternative testing that does not require sending the test to the lab) until the next testing date on 4/12/22. A line list for Tuesday, 4/5/22, documented 22 staff members had a COVID-19 PCR test out of 72 total staff members. The facility was unable to provide documentation that the staff who were not PCR tested had been POC tested until the next testing date on 4/8/22. The facility was unable to provide documentation that the staff members who were not tested had been contacted, provided education, been removed from the schedule, or had disciplinary action to ensure compliance with the testing requirements. B. Observations On 4/12/22 at 1:43 p.m., facility staff COVID-19 testing was observed. The social services assistant (SSA) getting ready to self-test in the DON office. The DON told the SSA to write his name and birth date onto the testing tube and also the bag. The DON did not provide the SSA with any other instructions. -He used the swab in a circular motion three times in each nostril. He then proceeded to place the swab in the tube and then placed the tube in the bag. He pumped the container to obtain hand sanitizer, however it made a sputtering sound, which indicated the hand sanitizer container was almost empty. -The door in the office, which led to the outside of the facility, was not open for ventilation. -The SSA left the room. The DON was informed that the SSA did not perform the COVID-19 self PCR test correctly. The DON said the swab should be twirled in a round fashion, five times in each nostril. She said he would have to return to conduct the test correctly to ensure an accurate result. At approximately 1:55 p.m. certified nurse aide (CNA) #12 came into the DON's office to conduct her COVID-19 test. The DON told her to make sure she twirled the swab in five full circles. The DON and the regional nurse manager (RNM) were in the room; they did not watch CNA #12 perform the self-test. CNA #12 swabbed each nostril four times. V. Failure to ensure the testing location followed CDC guidance for source control and failure to protect individuals, equipment and supplies, by keeping individuals and items six feet from the testing area and from each other. In addition, the failure to ensure infection control practices were observed during the testing process. A. Observations On 4/12/22 at 11:15 a.m. an unidentified housekeeping staff member was observed entering the DON's office for the COVID-19 PCR self-test. She approached the table, labeled the testing tube with her name as directed by the DON. -The DON was observed sitting at her desk, closer than six feet from the housekeeping staff member, with her face shield on the top of her head and the N95 respirator mask pulled beneath her chin. She was not wearing any other form of PPE. -The RNM was sitting at another desk in the room. She was wearing a N95 respiratory mask and a face shield. She was not wearing any other form of PPE. -The housekeeper, while performing the swab self-test, was informed by the DON she needed to turn around. The housekeeper turned to the area directly behind her. The area had boxes and packages of unopened PPE and testing supplies. She performed the swab self-test, placed the tube into a bag and then left the room. She did not perform hand hygiene after performing the test. At approximately 1:50 p.m., the SSA returned to complete the PCR test. He removed his mask and faced the DON while he did the swab test. He removed his gloves and then wiped down the table. He did not perform hand hygiene after testing. At 1:55 p.m., CNA #12 entered the DON's office to perform the COVID-19 self-test. After she was finished, she placed the swab in the tube and the tube in the bag. She did not perform hand hygiene following the self-test. VI. Staff interviews CNA #2 was interviewed on 4/12/22 at 3:43 p.m. She said staff were required to be tested twice a week on Tuesdays and Fridays. She said management informed staff they needed to be tested these days via the intercom system in the facility. She said testing was done in the DON's office. She said the testing supplies were set up and she tested herself each time. She said she used the swab in each nostril for three spins. She said she then placed the swab in a vial and handed it to the manager in the office. She said she then placed her mask back on and returned to work. She said she was required to get a rapid test prior to her shift when she had COVID-19 symptoms. The staffing coordinator (SC) was interviewed on 4/12/22 at 4:00 p.m. She said both direct hire and agency staff were notified in orientation that COVID-19 testing days were conducted on Tuesdays and Fridays. She aid then it was the staff' s responsibility to remember to get tested . She said agency staff signed a waiver prior to starting that stated they will be tested twice a week for COVID-19. She said if management noticed agency staff was not tested , that staff member would be reviewed in a compliance call on Thursdays with the agency. If agency staff continued to not get tested , the contract was terminated by the facility. Licensed practical nurse (LPN) #2 was interviewed on 4/12/22 at 3:36 p.m. She said COVID-19 testing days were on Tuesdays and Fridays. She said she got a notification via the phone as a reminder to get tested . She said she tested herself in the DON's office. She said hand hygiene should be performed prior to the test. She said the swab should be put into each nostril and twirled in a circular motion for a few seconds. She said she had only been rapid tested , not PCR tested , since starting at the facility three weeks ago. LPN #1 was interviewed on 4/12/22 at 3:30 p.m. She said all staff were tested twice a week for COVID-19, on Tuesdays and Fridays. She said she recently had COVID-19, so she was not required to take the test for 90 days. She said staff were notified to be tested via posted signs, in-person meetings, on the facility intercom, or a phone call. She said testing occurred in the DON's office. She said during testing, first she took off her mask, put a sticker with her name and birth date on the vial, swabbed each nostril for five seconds, put the swab in in the vial, put the vial in a biohazard bag, and then performed hand hygiene. CNA #5 was interviewed on 4/12/22 at 3:26 p.m. She said testing days were on Thursday and Friday afternoons before 2 p.m. She said if she had not completed her testing, she received a call from management to get tested . She said testing was conducted in the DON's office. She said a manager was in the office and conducted the test. The DON was interviewed on 4/12/22 at 2:14 p.m. She said the facility had completed 18 PCR COVID-19 tests for facility staff members. She said every staff member should be tested by 2:00 p.m. that day. She said the facility was in outbreak and staff were required to be tested twice a week. She confirmed the facility had a lot more employees than 18. She said she had been working at the facility for four days. She said based on the documentation she had seen and observations of staff being tested , she did not feel the facility was meeting the requirement of testing the facility staff as directed by the state health department. She said the testing location was not adequate because it was located in the DON's office. She said the office contained many boxes of PPE, testing supplies and other various items and paperwork. She confirmed the testing table was located in front of her desk and did not allow for her to be distanced by six feet. She confirmed boxes of PPE, testing supplies and documents on her desk were within fewer than six feet from the testing table. She confirmed the door, which led to the outside of the facility, was not open for ventilation. She confirmed she had not worn full PPE when facility staff members were performing the COVID-19 self-test. (See above) She said she wore an N95 respirator mask and a face shield but said she and the RNM should have donned full PPE while staff were in the office, testing. The RNM was interviewed on 4/12/22 at 3:45 p.m. She said they had been able to get 22 staff members tested today. She said the facility had over 70 employees. She said she was just made aware that not all the staff in the facility had been tested . She said the facility was only conducting rapid POC testing if the staff members were showing signs and symptoms of COVID-19, not if they missed the PCR testing on Tuesdays and Fridays. She said any residents or staff members who tested positive for COVID-19 went into a tracking system. She said after the testing occurred on Tuesdays and Fridays, the facility designated person could log into the laboratory system and get the results usually within 24 to 48 hours. She said the designated person at the facility had been the DON and the NHA. She said the DON resigned and the current DON did not have access to the laboratory system to obtain the test results. She said the facility would ensure the DON would have access to the laboratory system that day, 4/12/22. She said she looked at past test results and it appeared as though the facility had not been testing all 72 staff members, which was directed by the state health department because of the facility's outbreak status. The NHA was interviewed on 4/12/22 at 4:44 p.m. She said she had been out for a few weeks because her COVID-19 test had come back positive. She said the facility had been in outbreak status since 12/23/21. She said the facility conducted COVID-19 testing twice a week, on Tuesdays and Fridays. She said the facility utilized signs posted on the DON's office and time clock, text messaging system and word of mouth to remind staff of testing days. She said the facility had been having a difficult time keeping the agency staff accountable for coming and testing. She said the facility kept track of who had not been tested and had started compliance calls with the agencies approximately four weeks ago. She said there were 72 staff members who worked at the facility and were required to be tested . She said she was aware the facility had not been in compliance with testing all of the staff. She said she did not have any documentation to indicate staff members had completed rapid POC testing if they missed the required PCR test. She said staff should not be working if they did not get tested . She said she did not know what happened, but said the previous DON was allowing the staff to continue working without being tested . She said going forward, a new plan was being put into place for education, verbal and written warnings and termination for staff who missed testing.

Based on observations, record review and interviews, the facility failed to develop and implement a COVID-19 staff vaccination process to address all facility staff, including unvaccinated staff who provided care, treatment and other services to facility and/or residents. Specifically, the facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE (personal protective equipment) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. The facility was non-compliant with the requirement of 100% vaccination rate, except those exempted, because of its failure to adequately track all employees (vendors and contractors) vaccination status to prevent the spread of COVID-19. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement which indicated the provider agreed to comply with the facility's vaccination policy. Cross-reference F880 (Infection control), F886 (COVID-19 testing), F835 (Administration), F837 (Governing body) and F867 (QAPI). The facility was non-compliant with infection control practices to protect residents from contracting COVID-19. Observations on 4/6/22 to 4/12/22 showed: -Facility staff did not consistently wear N95 or equivalent respirators while engaged in resident care and in resident areas and did not follow required use of eye protection in an outbreak. -Facility staff did not perform hand hygiene appropriately in between caring for residents and tasks; - Equipment (medical and non-medical) was not sanitized in between use; -Re-use of gowns in COVID-19 positive rooms and improper donning of gowns in COVID-19 positive rooms and lack of sanitization of face shields; -Facility staff not performing hand hygiene in between rooms/residents; -Facility staff were not providing residents with hand hygiene prior to meals; and, -Facility staff were not properly cleaning tables in the dining rooms after resident use. -Facility staff were not properly cleaning resident rooms. Since 3/22/22, 18 residents have tested positive for COVID-19. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy The facility failed to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. During the survey, 4/6 through 4/19/22, the facility was unable to provide a listing of the vaccination status of all contracted providers/staff who enter the facility on a regular basis and provide direct care to residents. The facility was non-compliant with the requirement of 100% vaccination rate except for those exempted, because of its failure to adequately track all employees (vendors and contractors) vaccination status to prevent the spread of COVID-19. A review of the facility vaccination policy and procedure revealed the facility did not require proof of vaccination for all contracted providers, but instead, required a generalized provider company attestation agreement, which indicated the provider agreed to comply with the facility's vaccination policy. Observations revealed the facility was non-compliant with infection control practices to protect residents from contracting COVID-19.(Cross-reference F880) Observations on 4/6/22 to 4/12/22 showed: -Facility staff did not consistently wear N95 or equivalent respirators while engaged in resident care and in resident areas and did not follow required use of eye protection in an outbreak. -Facility staff did not perform hand hygiene appropriately in between caring for residents and tasks; - Equipment (medical and non-medical) was not sanitized in between use from a COVID-19 positive resident to a negative and unvaccinated resident; -Facility staff re-using gowns in COVID-19 positive rooms and improper donning of gowns in COVID-19 positive rooms and sanitization of face shields; -Facility staff not providing residents with hand hygiene prior to meals; and, -Facility staff not properly cleaning tables in the dining rooms after resident use or properly cleaning resident rooms. Since 3/22/22, 18 residents have tested positive for COVID-19. B. Imposition of immediate jeopardy On 4/13/22 at 1:00 p.m., the nursing home administrator (NHA) and the regional nursing consultant (RNC) were notified of the immediate jeopardy situation created by the facility's failure to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. C. Facility plan to remove immediate jeopardy On 4/14/22 at 2:32 p.m. the facility submitted a plan to remove the immediate jeopardy. The plan to remove the immediacy read: 1. Corrective action -On 4/14/22, the nursing home administrator and/or designee contacted all contracted providers to obtain verification of vaccination for all providers who enter the facility on a regular basis. This will be completed by 4/14/22 as any incoming vendor will be asked for proof of vaccination. The human resources director will continue to review and ensure outside contractors are fully vaccinated or have an approved exemption with a copy of their vaccination card and exemption on file. -On 4/14/22 a healthcare vaccine mandate vendor communication contract was developed and distributed to contracted vendors with the stipulations of the facility's requirements for verifying each provider's vaccination status, and the PPE strategies for those with accepted exemptions. Each contract will be signed and the facility will keep a copy by 4/14/22 or prior to allowing vendors into the facility. -All new contracted staff members' vaccination status and/or exemptions will be reviewed by the human resources director and documented on the vaccination log. -A list of contracted staff members' vaccination dates will be documented on the contracted staff member's vaccination log by the HRD or designee. -The receptionist or scheduler will validate the contracted staff member's vaccination status prior to having contact with the residents. -If a contracted staff member's vaccination status is unknown, the human resources director will request a copy from the contracted vendor prior to entering the facility. 2. Systemic changes -Education was provided to the nursing home administrator, director of nursing, and human resources director on the vaccination requirements and the Healthcare Vaccine Mandate Vendor Communication on 4/13/22. 3. Monitoring -Interdisciplinary team, to include the medical director, will conduct a root cause analysis to determine the progress of the corrective plan and will provide a report to the quality assurance performance improvement committee to discuss recommendations and additional corrective actions. D. Removal of the immediate jeopardy The NHA and DON were notified on 4/14/22 that the above plan was accepted on 4/14/22 at 3:13 p.m. based on the facility's plan above, and the immediate jeopardy was removed. However, deficient practice remained at F level, deficient practice that is widespread. II. Facility policy and procedure The Mandatory COVID-19 vaccination policy and procedure, revised January 2022, was provided by the NHA on 4/6/22 at 2:00 p.m. It read, in pertinent part, This COVID-19 vaccination policy applies to all employees, resident providers, independent providers, volunteers, students, contractors, and vendors who work in a healthcare facility or provide healthcare services in a client's home. Senior care (includes skilled nursing): be fully vaccinated or have an approved medical or religious exemption. Employees are considered fully vaccinated two weeks after completing primary vaccination with a COVID-19 vaccine, with if applicable, at least the minimum recommended interval between doses. For example, this includes two weeks after a second dose in a two-dose series, such as the Pfizer or Moderna Vaccines, two weeks after a single-dose vaccine, such as the Johnson & Johnson vaccine, or two weeks after the second dose of any combination of two doses of different COVID-19 vaccines as part of one primary vaccination series. Employees and volunteers are required to provide proof of COVID-19 vaccination. Employees and volunteers vaccinated by [the facility] already have proof of vaccination status. All other employees are required to provide proof of COVID-19 vaccination to their local human resources designee. Acceptable proof of vaccination status is one of the following: the record of immunization from a healthcare provider or pharmacy; a copy of the COVID-19 vaccination record card; a copy of medical records documenting the vaccination; a copy of immunization records from a public health, state, or tribal immunization information system; and a copy of any other official documentation that contains the type of vaccine administered, dates of administration, and the name of the healthcare professionals or clinic site administering the vaccine. All contractors and business partners who have a recurring interaction with staff, patients, or residents, by contract or other arrangement, are required to comply with the vaccination requirements outlined in this policy prior to performing work in a facility. This includes but is not limited to licensed practitioners/independent medical staff, students, and trainees. III. Failure to monitor each contracted staff member's vaccination status to ensure proper advanced PPE strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. A. Record review The vaccination matrix, provided by the NHA on 4/6/22 at 4:00 p.m., documented a list of facility staff members, including agency staff. It indicated each staff member's vaccination status, including if any exemptions had been approved. It included 66 staff members in the nursing, housekeeping, dietary and administration departments. The vaccination matrix did not include any providers, such as physicians, nurse practitioners, or hospice staff. The Mandatory COVID-19 vaccination policy and procedure, revised January 2022, documented the following: Agencies, universities, and other contracted services who have employees or students present in our facilities that provide care, treatment, or other services for the healthcare location or patients must provide a signed attestation statement that all their employees or students are vaccinated or have a qualifying exemption. The Vendor Vaccination Attestation documented The [vendor organization's name] agrees to comply with [the facility's] vaccine requirements based on the interim final rule issued by the Centers for Medicare and Medicaid Services (CMS) in the Department of Health and Human Services. Vendors who have employees or students present in our facilities who provide care, treatment, or other services must provide a signed attestation statement that all of those employees or students are vaccinated or have a qualifying exemption and will do the following: Upon request, and only upon request, provide additional data of vaccination status. The facility provided a binder of documented attestations during the survey process from different vendor agencies; however, the facility was unable to provide documentation of each specific provider's vaccination status who entered the facility and provided direct care to residents. The facility failed to have a monitoring system in place to ensure each provider who entered the facility and provided care to residents was fully vaccinated or had an exemption and was exercising the facility's PPE (personal protective equipment) requirements while in the facility. IV. Staff interviews The NHA was interviewed on 4/12/22 at 4:44 p.m. She said the facility kept track of the vaccination status of all of their staff, including agency staff. She said she had 66 staff members documented on the staff vaccination matrix, which included their vaccination status and any with approved exemptions. However, she confirmed the facility had 72 employees and acknowledged that not all facility staff members were included on the staff vaccination matrix. She also confirmed providers, such as physicians, nurse practitioners, or hospice staff, were not included on the staff vaccination matrix. She said the facility policy was to get an attestation from the provider's agency to ensure vaccination status. She said each physician's medical group or hospice agency should have an attestation on file indicating their staff was vaccinated. She said the facility did not have copies of each individual provider's vaccination card or exemption. She said the facility had not been tracking each individual provider's vaccination status. She said she thought the group or agency's attestation was enough.

Based on observations, record review and interviews, the facility failed to implement interventions and provide appropriate treatments to prevent the development and worsening of pressure injuries for three (#6, #40 and #282) of six residents reviewed for pressure injuries out of 33 sample residents. Resident #6 had resided in the facility since 2017 for long term care. The resident had [CONDITION(S)], [CONDITION(S)], and diabetes type 2. He wore custom modified orthopedic boots on both legs due to the acquired absence of his right foot. Record review revealed the facility did not ensure the resident's feet were monitored daily before and after a boot modification for tissue damage or signs of pressure or rubbing to prevent skin breakdown. -On 3/10/22, Resident #6 attended a scheduled physical therapy session with an outside provider when two wounds on his left leg were discovered. During his therapy session, the resident's left boot was removed and upon the removal of the sock, a long piece of skin came with. The sock was covered in serosanguinous, foul smelling drainage. The wound bed was red, and took up the entirety of the heel. Resident was sent back to the facility with dressing change orders. However, the dressing changes were not completed as ordered and the resident's wounds deteriorated. -On 3/29/22, Resident #6 attended another scheduled physical therapy session with an outside provider. Upon removal of the wound dressings, profound macerated and peeling skin was noted on 90% of the left foot, severe redness over top of the foot, increased swelling up to below the knee and several new open areas. The resident's primary care provider (PCP) was contacted and instructed that the resident be sent to the emergency department (ED) for evaluation. Resident #6 was evaluated and admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . He received antibiotic treatments and debridement of the wound. Furthermore, after the resident developed tissue injury from his orthotpedic boot, the facility did not develop or complete a performance improvement plan or implement prevention measures to prevent this from happening again to other residents. There was no evidence staff had been educated on the use and placement of orthopedic devices. Cross-reference F867. The facility's failure to assess and monitor Resident #6 for pressure injuries due to his orthopedic devices created an immediate jeopardy situation for serious injury to reoccur if immediate corrective action was not taken. In addition to Resident #6, the facility failed to put interventions in place to prevent the development of stage 3 pressure injuries for Resident #40 and #282. Resident #40 had a left sided weakness on upper and lower extremities and required assistance with turning and repositioning. The resident was not consistently assisted with repositioning, his heels were not elevated and he developed a stage 3 pressure injury on his left heel. Resident #282 was admitted to the facility with no pressure injuries and developed two stage 3 pressure injuries during her stay. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Resident #6, diagnosed with [CONDITION(S)], [CONDITION(S)], and diabetes type 2, wore custom modified orthopedic boots. He developed a pressure injury to his left heel on 3/10/22, which progressed to an unstageable 7 centimeters (cm) by 11 cm wound, and by 3/29/22, had become infected. The resident required hospitalization and evaluation by a wound care specialist. He was diagnosed with [CONDITION(S)] due to wound infection. The resident underwent [MEDICAL RECORD OR PHYSICIAN ORDER] The facility did not ensure the daily skin checks were completed before a boot modification to monitor for tissue damage. The facility further failed to complete skin assessments after boot modifications to ensure the resident's skin was consistently monitored for signs of pressure, rubbing or breakdown. Furthermore, after the resident developed tissue injury, the facility did not develop or complete a performance improvement plan or implement measures to prevent this from happening again to other residents. Cross-reference F867. The facility's failure to assess, monitor and treat Resident #6 for pressure injuries created an immediate jeopardy situation for serious injury to reoccur if immediate corrective action was not taken. On 4/13/22 at 2:20 p.m., the nursing home administrator (NHA) was notified that the findings regarding Resident #6 created a situation of immediate jeopardy for serious harm. B. Plan to remove immediate jeopardy On 4/14/22 at 1:35 p.m., the facility submitted the following plan to remove the immediate jeopardy situation: 1. Immediate actions -On 4/13/22, a skin assessment was completed by Director of Nursing and nursing team for every resident in the facility. All new findings and worsening of wounds were documented in the resident's medical record, the physician was notified and new treatment orders were obtained. -On 4/14/22, all current treatment orders were observed to ensure accuracy and frequency of treatments were being completed according to physician orders. All negative observations were immediately corrected and on the spot education was provided to the nursing staff. -On 4/13/22, a sweep was completed by Director of Nursing to identify each resident with an orthopedic device. A review of each resident's medical record with an identified orthotic will be completed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The review will be completed by 4/14/22. -All orthotic devices, including Prevalon boots that are used to offload heels, will be scheduled to be disinfected/cleaned daily by Director of Nursing or designee, and will be checked for proper functioning prior to application, -All residents who were identified with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The skin checks will be documented in the resident's medical record. -The director of nursing and/or designee will complete daily audits of the treatment administration record to ensure wound care was completed according to physician orders. -The director of nursing and/or designee will complete treatment observations to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The director of nursing and/or designee will track the observations to ensure compliance. -The Nurse Practitioner or designee will be assigned as the wound nurse and will conduct weekly wound rounds, document the progress and any new findings of the wound, and track all wounds in the facility. -Each resident will have a skin assessment completed weekly and documented in the resident's medical record on the skin assessment form by a licensed nurse. The skin assessment will include any new, current, on-going and resolved skin concerns. It will indicate if the resident has no skin concerns. The physician will be notified of any new or worsening skin conditions and documented in the resident's medical record. The wound nurse will be notified of any new skin concerns via phone call or in person. -Residents with newly identified skin conditions will be assessed for a change of conditions and monitored for 72 hours on Alert Charting Log. -All wound care notes from all wound care providers will be scanned and kept in the resident's medical record. 2. Systemic Changes The director of nursing or designee will provide education to all licensed nurses on 4/14/22. The education will include: each nurse will conduct a skin assessment of the resident when a new skin condition is reported by other disciplines (CNAs during the shower, PT/OT, etc), the notification of the physician when new or worsening skin conditions/pressure injuries are observed, all new or worsening wounds should have treatment orders documented in the treatment administration record, ensuring all orthotic devices are removed and the skin is inspected daily and documented in the resident's medical record, and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Any licensed nurse not educated on 4/14/22 will receive training prior to their next scheduled shift. 3. Monitoring Interdisciplinary team, to include the medical director, will conduct a root cause analysis to determine the progress of the corrective plan and will provide a report to the quality assurance performance improvement committee to discuss recommendations and additional corrective actions. C. Removal of immediate jeopardy On 4/14/22 at 1:35 p.m., the NHA was informed that the facility's plan to remove the immediate jeopardy was accepted, based on the review of the facility's plan to address systemic issues in pressure injury management. However, deficient practice remained at H level, actual harm at a pattern. II. Facility policy and procedure The Skin Management Guidelines policy and procedure, dated March 2022, was provided by the director of nursing (DON) on 4/18/22 at 3:25 p.m. In pertinent part, it read: -Skin alterations and pressure injuries are evaluated and documented by the licensed nurse. -Body audits are completed by the licensed nurse daily for patients with pressure injuries and documented on the TAR (treatment administration record); new findings are documented in the progress notes. -The Pressure Ulcer Scale for Healing (PUSH Tool) is used to document the healing status of pressure injuries. It is initiated upon identification of a pressure injury and is updated weekly by the wound team during wound rounds until wound heals. -Wound rounds are completed weekly on pressure injuries and complex wounds. IV. Resident #6-Multiple failures in assessment, monitoring and care, contributing to the development of pressure injuries that worsened. A. Resident #6 status Resident #6, age 67, was admitted to the facility 11/22/2017. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/23/21 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. He had no behavioral problems, [CONDITION(S)], or rejection of care. He required extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. He was at risk of developing pressure injuries and had no pressure injuries at the time of admission. He had pressure reducing devices for his bed. He was marked as not having any functional limitations in his arms or legs. Record review revealed that due to the absence of his right foot, the resident wore orthopedic boots for mobility and had done so since admission. The Braden scale assessment on 12/23/21 revealed a score of 18, indicating mild risk for pressure injuries. B. Resident interview and observations Resident #6 was interviewed on on 4/12/22 at 12:10 p.m. Resident #6 was lying in bed on his back. He was displaying constant involuntary movement of his arms and legs. The resident had Prevalon boots on both of his legs. The stump of the right leg was partially sticking out of the Prevalon boot due to continuous involuntary movements. A large (about 7 cm by 2 cm) scab on the upper shin was rubbing against the strings of the boot. The Prevalon boot on the resident's left leg had visible curlex covering most of the ankle. Four toes with multiple black scabs on top of each toe were sticking out of the boot. Space between the toes was packed with red to black debris, possibly skin. There was no visible space between the toes. Resident #6 said his right foot was amputated a while ago and since then, he had been wearing custom made boots on both legs for ambulation. A few weeks ago, his left boot got modified and it was at about this time he started to develop wounds on his left foot. He said his wounds were discovered during a physical therapy session with an outside provider. He said the wound started as a small area and later deteriorated to a large wound. He said his wound dressings were not changed routinely and day and evening nurses would say the dressings were scheduled to be done during the night shift. However, the night shift nurses would not change the dressings either. He said he was seen by an outside physician for wound care at least once a week and that was almost the only time his dressings were changed. He said the lack of wound care in the facility contributed to the deterioration of his wounds and he was hospitalized a few weeks ago with [CONDITION(S)]. He said since he returned from the hospital, the wound care in the facility had not improved and nurses continued to skip dressing changes. C. Wound care observation Wound care observations were conducted on 4/13/22 at 11:41 a.m. in the presence of licensed practical nurse (LPN) #1 and the unit manager (UM). -Left leg: LPN #1 removed the velcro strip on the left Prevalon boot and opened it up. Upon opening, a large wound on the lateral side of the shin was observed. The wound was stuck to the inside of the Prevalon boot and saturated with red bloody drainage.The wound was about 3 cm by 6 cm with clear to bright red fluid seeping through its entire surface. The ankle was completely wrapped in curlex. The curlex on the heel area had a large black to red stain extending through the entire heel. It was partially dry and partially wet. The wet section of the curlex saturated the Prevalon boot and stained it with red to black drainage. Removal of the curlex revealed several foam dressings on the side and the top on the ankle. The foam dressings were saturated in dark red drainage and no longer were sticking to the tissue. The foam dressing on the heel was dated 4/12/22. Green xeroform dressings were removed together with foam dressings, and revealed multiple open areas covering the entire ankle with the largest open area covering the entire bridge of the foot. All open areas were seeping clear to pink drainage. The entire area on the heel presented with unstageable black wet eschar. The tissue between the wounds was cleaned with skin prep solution. Xeroform dressing was applied to open areas. treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The rest of the ankle and open areas were covered by ABD pads (absorbent multi-layer pads) and curlex. E. Record review-Record review revealed multiple failures in assessment, monitoring, care planning and treatment, contributing to the development of pressure injuries that worsened, became infected, and required hospitalization . 1. Failure to properly assess and care plan Resident #6's risk for pressure injuries prior to orthopedic boot modification. a. Record review revealed the resident experienced trauma, the potential for pressure injuries and wounds in January 2022 and February. There was insufficient documentation that the resident's injuries and potential for injuries were assessed, monitored, and treated. According to a skin progress note 11/30/21, wound care physician (WCP) #1 rounded on patient on left skin tear and per his observations, resident did not have any skin tears or wounds. There were no additional skin/progress notes until 1/18/22. However, on 1/18/22, a skin/progress note documented resident acquired traumatic skin tear to left shin (2 cm by 1.6 cm). No redness or irritation of surrounding skin. Care plan in place to promote healing and to prevent additional ulceration and infections. Treatment orders were to clean with normal saline, and to apply foam dressing daily. The treatment administration record (TAR) for January 2022 revealed the resident had an order in place to apply skin prep to bilateral heels and left plantar (bottom foot) for prophylaxis every third day. The order was discontinued on 4/8/22 (during survey). The resident also had an order in place to use a leg elevating device for the left leg while in bed, to make sure the left heel was floating. The order read to cover the device with absorbent pad due to wound drainage. The order was consistently signed by nurses three times a day, and was discontinued on 4/11/22 (during survey). Yet, the care plan for skin integrity, initiated on 11/22/17 and revised 1/4/22, while noting the resident's risks associated with immobility and incontinence, did not address skin tears or his use of orthopedic devices on his feet. Further, there was no mention of a wound on the left heel on the TAR, in progress/skin notes or care plan in January 2022. 2. Record review revealed the resident received new orthopedic boots in February 2022. Although skin breakdown was documented thereafter, record review revealed no planned interventions to monitor the resident's lower extremities to prevent his skin breakdown from worsening. On 2/11/22, the resident was seen by a physical therapist (PT), outside of the facility, who documented in her notes that the resident received his new boots and has been wearing them for the last two months. He had no problems on the right leg. On the left leg he had several areas that have broken down skin with some wounds. Resident said the wounds were discovered at the wound care clinic that he went to and dressing was put on at that time. He had two areas on his shin that were open and appeared to be shear type areas from the front of the boot, and several other areas. On 2/15/22, a wound clinic note mentioned the resident had multiple open wounds to left leg. A total of four open areas were documented, two on the ankle and two on the shin. All open areas were measured less than 1 cm, with granulation tissue and small serosanguinous drainage. Recommendations included to maintain wound care appointments and notify the clinic of any changes to wounds. On 2/17/22, the wound clinic note documented a total of two wounds on the left lower leg. Wound #1 was on the left plantar side and wound #2 was on the left upper ankle. Both wounds measured less than 1 cm. Recommendations included to clean both wounds with wound cleanser, apply skin prep to peri wound, and apply [MEDICATION(S)]. In addition, off-loading and taking shoes off during the day. On 2/24/22 wound clinic note documented wound #1 had thick serosanguinous drainage with foul odor. The wound was beefy red with well defined edges, measured 1 cm by 0.5 cm, and appeared to be pressure related. TAR review for February 2022 revealed the resident received: - two treatments to right shin skin tear on 2/1 and 2/2. The order was discontinued after 2/2/22; -skin prep to bilateral heels at bedtime every third day; -leg elevating device for left heel since last month. Notwithstanding documentation of the resident's wounds, review of the resident's care plan for skin integrity revealed no update to ensure daily monitoring of the resident's feet and no documentation in the progress notes that showed staff was assessing the resident's skin under the orthopedic boots. Further, there were no additional orders to address the wounds that were documented in the wound clinic notes. 3. Record review revealed the facility failed to consistently assess and monitor the resident's feet, as well as consistently treat the resident's skin breakdown, contributing to new wounds, infection, hospitalization , loss of mobility and left leg [CONDITION(S)]. On 3/1/22, the resident attended a physical therapy session with an outside provider, who documented the following findings: old left shin wound is healed, however new wounds are on left dorsum of the foot near ankle. On 3/1/22, the wound clinic noted the resident had a wound on his right foot, measuring less than 1 cm, beefy red, pressure point related to boot. The wound notes did not mention the left leg. On 3/3/22 the wound clinic note documented the resident had wound #1 on his left foot, the wound measured less than 1 cm and was a skin breakdown in type. Treatment included to clean the wound and apply foam dressing. On 3/7/22, the wound clinic note read: we did not see much of anything on his left leg, except for an abrasion on his left upper leg from the boot that he had on. On 3/10/22, the resident attended a physical therapy session with an outside provider. The resident was not able to participate in therapy and said he did not feel great today. He shared with the therapist that nurses at the facility were not attending the areas on his feet. The PT inspected the left leg and observed left heel open area with bloody drainage on the sock and heel. The PT documented, the open area approximately near the area that the orthotic insert may be rubbing with the heel lift that was put in the boot on 3/8/22. PT notified the wound clinic and replaced his orthopedic boot with a large walking boot. On 3/10/22, a progress note by the facility nurse documented that she received a call from the wound clinic that the resident had pressure ulcers on his legs. She received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/11/22, a progress/skin note by the facility nurse revealed the resident had two wounds. Wound #1 was on the left heel measuring 1.5 cm by 1.6 cm by 0.1 cm., Wound #2 located on the left shin and measuring 2 cm by 2 cm by 0.1 cm with serosanguinous drainage present. Report was received from the wound clinic indicating the pressure ulcer was a result of adjustment made to the boot. Two care plans were initiated 3/11/22. One documented the resident had an open wound on front of left lower leg related to orthopedic boots. The goal was to provide treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions include administering treatments per physician order, and applying Prevalon boot at night while in bed. The other care plan documented the resident had an unstageable pressure ulcer on the left heel related to orthopedic boot. Interventions included to administer treatment per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] However, the walking boot that the resident now was using on his left leg after it was provided by therapy 3/10/22 was not mentioned in progress notes, TAR or the resident's care plan. There was no evidence that proper placement and care was completed. On 3/13/22, a progress/skin note by the facility nurse documented the same wound observations and measurements as above. Even though wound care treatment orders were initiated by the facility on 3/11/22 (after the wounds were discovered during the PT session on 3/10/22), notes from therapy sessions indicated skin assessments, monitoring and the treatments were not consistently completed by facility staff. Specifically: On 3/15/22, the resident attended the next scheduled therapy session. During the session, the nurse in the clinic was asked to assess his left heel. When (the nurse) took off the sock, a long piece of skin came with it. Patient's sock was covered in serosanguinous foul smelling drainage. The wound bed was red, and took up the entirety of the heel. The shin wound started to open up. A new wound was discovered on the back of the left calf. Resident #6 was sent to the PCP's clinic and seen by the nurse practitioner at that time due to a rapid change of condition. Blood tests and urine work were completed. On 3/17/22 during a physical therapy session, resident was not able to participate in ambulatory (walking) exercise due to a wound on the left heel. On 3/17/22, the resident was assessed in a wound care clinic; two wounds were observed. -Wound #1 located on the left heel: dressing was rolled up and it was saturated with serous drainage. Unstageable black eschar [was] covering most of the wound bed. Full thickness tissue loss in which the base of the ulcer is covered by slough and eschar in the wound bed. Treatments included to cleanse the left heel with wound cleanser or normal saline. Pat dry, and apply [MEDICATION(S)] dressing. Change daily and off-load. -Wound #2 located on the left lower extremity below the knee and was caused by velcro from the walking boot. The wound was healing. Treatment order included to clean with wound cleanser and apply foam dressing. -The measurements for both wounds were not recorded on the notes. On 3/21/22, the resident attended a scheduled wound care clinic visit, new ulcerations on the left foot were noted. The exam revealed [O]bvious [CONDITION(S)] occurring in the left extremity that was not noticed at last visit. -Wound #1 Plantar (on the sole) posterior (back) aspect of the left calcaneus (heel) shows an unstageable pressure injury. Devitalized tissue around the site with large eschar formation in the center. Measurements of the wound were not included in the notes. -Wound #2 was very large unstageable pressure injury to the left heel caused by the boot. The wound was measuring 7.5 cm by 11 cm., with poorly defined wound edges and macerated moist peeling skin around it. Treatment consisted of sharp debridement, the area was cleaned and new dressing was applied. The wrap was applied to the left leg as well to control [CONDITION(S)]. Facility was contacted over the phone and treatment orders for the resident were discussed with the nurse on duty. The facility was notified to watch for signs and symptoms of potential infection and plan to re-evaluate the resident in two weeks. The facility failed to take steps to prevent further decline in the resident's condition, as ordered. -Progress notes and TAR review demonstrated that above recommendations for [CONDITION(S)] management and monitoring for infection were not added to the resident's medical record. There was no evidence in the resident's progress notes that the resident was monitored for [CONDITION(S)] and potential infection on his left leg. No additional progress/skin notes were located in the resident's medical record regarding the further deterioration of his wounds. -The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Specifically: -The Prevalon boot was applied at bedtime to relieve the pressure on the heel (did not specify right or left). The order was initiated on 3/11/22, it was not signed as complete on 3/26/22. -Weekly body audits were signed as completed on 3/3, and 3/10/22, and on 3/15/22, body audits were switched to weekly despite the resident's decline. The audits were signed as completed every day except for 3/16 and 3/22/22. -Dressing changes for pressure ulcer on left front lower leg were initiated on 3/11 and discontinued on 3/23/22. The order was not signed/completed on 3/16, 3/21, 3/22, and 3/23/22. Additional orders for the same wound were initiated on 3/23/22 and read that dressing changes were scheduled to be done on Mondays, Wednesdays, and Fridays by the wound care clinic. The order was not complete/signed on 3/25/22. -Dressing changes for the pressure ulcer on the left heel were initiated on 3/11/22. The treatment order changed on 3/19/22 and was changed again on 3/25/22 to be completed on Mondays, Wednesdays, and Fridays by the wound care clinic. The order was not signed/completed on 3/16, 3/21, 3/22, 3/23 and 3/25/22. - Despite documentation of skin breakdown on the resident's heels, skin prep to bilateral heels at bedtime every third day was consistently signed as completed during the entire month of March. -Off loading left heel at all times was initiated on 3/23/22 and was not signed/completed on 3/25, 3/26, and 3/27/22. -Leg elevating device for left leg (initiated in January 2022) was not signed/completed on 3/2, 3/25, 3/26 and 3/27/22. See above; the wound care treatment orders were conflicting with one order calling for skin prep to the left heel and another one for dressing changes. In addition, some wounds and abrasions that the resident had on both legs early in March (see notes above 3/1 and 3/3/22) were not treated or documented in progress notes or TAR. On 3/29/21, the resident attended a regular PT session outside the facility. The nurse was called to the room to assess the wounds. Full removal of the dressings note worsening wounds, profoundly macerated and peeling skin on 90% of foot, severe redness over top of foot, that was taught and shiny. Also, increased swelling up to below knee with rubby skin and several new areas of concern that are open, with eschar areas to great toe, second toe and fourth toe. Resident reported that his dressings were changed but once since his appointment at the wound clinic over a week ago. The PCP was contacted and an order was received to send the resident to the emergency department for evaluation. 4. hospitalization -documentation of decline According to the hospital admission records dated 3/29/22, the resident was seen in the emergency department on 3/29/22 for redness on his foot that got more red over the last two weeks. The resident was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident with [CONDITION(S)] and multiple wounds on left foot. Left foot and lower leg are three times larger than the right leg. The resident was started on intravenous (IV) antibiotics and wound treatments with antimicrobial gel. Several open areas were located on resident's legs, such as unstageable pressure injury to the left heel, measuring 9 cm by 9 cm; left foot plantar wound with unknown and potentially traumatic origin due to large amount of [CONDITION(S)], measuring 9 cm by 13 cm., wounds on 1st, and 2nd toes measuring 1 cm each; two venomous ulcers on right leg measuring 3 cm by 3 cm and 9 cm by 9 cm. Resident #6 was seen by a wound care specialist daily. He underwent sharp debridement and wound care treatments. The resident was discharged back to the facility six days later on 4/4/22. He continued to receive oral antibiotics for [CONDITION(S)] for the next 10 days, until 4/14/22. Recommendations included to continue antibiotics therapy, off load pressure injuries and provide daily dressing changes. The Braden Scale Observation/Assessment (for predicting pressure sore risk), dated 4/4/22, revealed a score of 16, which indicated the resident was at moderate risk for the development of pressure injuries. The section 7 on the form contained a question whether to proceed to the preventative care plan and to the wound/skin care plan; the answer to which was marked as no. F. Staff interviews-Confirmation of facility failures in assessment, monitoring and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Nurse Practitioner (NP) #1 was interviewed on 4/12/22 at 10:55 a.m. She said she was a primary care NP who worked with the resident in conjunction with the PCP. She said she was very familiar with the resident and had seen him frequently. -She said the resident was attending a therapy session in her building on 3/29/22 when the swelling of his left leg and wounds was brought to her attention. She said the swelling of his leg was so significant that she was surprised how that went unnoticed by the facility staff when they helped the resident get dressed for the appointment. She said the [CONDITION(S)] infection was very clear, and she sent the resident directly to the emergency department as she felt he needed immediate interventions. She said his wounds appeared neglected and not tended to for several days. -She said she observed the resident previously in the facility on several occasions and he reported to her that nurses were not changing his dressings. Specifically, on one of her assessment days, she observed a

Based on interviews, record review and observations, the facility failed to ensure the resident had the right to be free from involuntary seclusion not required to treat the resident's medical symptoms for one (#59) of three out of 33 sample residents. Specifically, the facility failed to ensure Resident #59 was kept free from involuntary seclusion which resulted in psychosocial harm. Resident #59, who had a documented history of anxiety, claustrophobia and was totally dependent upon staff, activated her call light on 3/19/22 to get staff assistance. The resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility staff closed the resident's door, against her wishes (which was documented in the resident's plan of care), because the resident was disturbing others, effectively secluding the resident against her will. The resident's wishes of keeping her door open while she was alone was well documented in the resident's medical record and staff interviews revealed the facility staff had been aware of the resident's wishes for over a year. The resident stated, in an interview with the psychologist four days after the incident, with the door shut, no one could hear her call for help. She felt the staff were punishing her, felt she was suffocating, her heart was racing and thought she might die. After the incident, an interview with the social services coordinator (SSC) documented Resident #59 replayed the event since it occurred, caused her emotional distress and had a continued negative psychological and emotional effect on the resident daily. Findings include: I. Facility policy and procedure The Patient Protection policy and procedure, dated October 2021, was provided by the nursing home administrator (NHA) on 4/6/22 at 2:00 p.m. It revealed, in pertinent part, The most critical step toward detecting and preventing abuse is acknowledging that no one should be subjected to violent, abusive, humiliating, exploitative or neglectful behavior. -Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Mental abuse includes, but is not limited to humiliation, threats of punishment or deprivation. -Involuntary seclusion is defined as separation of a patient from other patients or from his/her room or confinement to his/her room (with or without roommates) against the patient's will, or the will of the patient's legal representative. II. Failure to ensure the resident was kept free from psychological abuse A. Resident #59 status Resident #59, age 85, was admitted on [DATE] and readmitted on [DATE]. According to the April 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 3/4/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. It indicated the resident did not exhibit physical or verbal behaviors during the assessment period. The resident rejected care for four to six days during the assessment period. B. Resident and frequent visitor interview Resident #59 was interviewed on 4/6/22 at 2:49 p.m. She said she did not like it when the staff shut the door to her room. She said she was claustrophobic and with her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she was totally dependent upon staff for all of her care and was unable to get out of bed without assistance. She said she was not able to walk. She said she had been at the facility for quite a few years and felt the staff did not like her very much. She said there was a history of the staff not answering her call light timely so she had gotten into the practice of yelling out for help when she pushed her call light. She said she felt the facility staff would not answer her call light unless she yelled out. She said the staff at night were particularly bad about answering her call light. She said Saturday night, on 3/19/22, she had activated her call light because she needed to be changed because of a bowel movement. She said the staff did not answer, so she began to yell out, answer my call light and I need help. She said one of the certified nurse aides (CNA) came to her room, stood in the doorway, told her to stop screaming, told her she was being disruptive to other residents, and then shut the door. She said she felt like she was being punished. She felt like she could not catch her breath and started to panic. She said she screamed as loud as she could for help. She said she did not know how much later, after she started screaming, a nurse entered her room to help her. The nurse sat with her until the CNAs came back to provide incontinence care. She said she told the social services coordinator (SSC) about what happened and he completed a form (trauma informed care evaluation, see under record review). She said she did not feel as though anything was done. She said she still gets blamed for calling out when she activates her call light. She said she would not call out if she trusted they would answer her call light. A frequent visitor with knowledge of the resident was interviewed on 4/11/22 at 12:18 p.m. She said it was a known fact at the facility that Resident #59 did not want her door to be closed. She said the facility had been aware of this for at least over a year, if not longer. She said Resident #59 was afraid the facility staff would not answer her call light if she had an emergency. She said it caused distress to the resident, which was why when she pushed her call light, she would also yell out for help. She said the facility had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said, in the past year, the facility had been using a lot of agency staff. She said many residents had reported an overall attitude with the staff toward the residents, felt they were overworked and when they entered a resident's room, the staff were quick to get in and out and not really addressing the resident's needs. C. Observations On 4/11/22 at 11:31 a.m. Resident #59 activated the call light. CNA #4 was walking down the hallway and entered the resident's room. CNA #4 turned off the call light and walked back to the nursing station. Resident #59 reactivated the call light and began yelling out, where did my aide go,and come back and I need to be changed. CNA #4 was observed grabbing towels, sheets and walking slowly down the hallway toward the resident's room. CNA #4 arrived at the doorway of Resident #59's room at 11:42 a.m. She pulled down her N95 respirator mask, and yelled from the doorway, I told you I was going to get supplies. What do you want me to do, slip and fall? CNA #4 then entered the room and shut the door. Another CNA entered the room to assist a few minutes later. Both CNAs exited the resident's room at 11:53 a.m. after providing the resident incontinence care. -At 11:54 a.m. Resident #59 activated her call light. After two minutes, the resident yelled out, I need a nurse. CNA #4 told licensed practical nurse (LPN) #2 I have no idea what she needs. We just got out of there. Resident #59 began yelling out, I need Tylenol, and please answer my call light and please just answer my call light. LPN #2 opened the medication drawer, pulled out a medication and put it into a medication cup. She lifted her head toward the ceiling, let out a deep breath, locked the medication cart and entered the resident's room. -At 12:00 p.m. Resident #56 activated her call light. The CNAs were observed passing out meal trays for lunch and LPN #2 was standing at the medication cart in close proximity to the resident's room. Resident #59 yelled out, I need a blanket. LPN #2 shook her head, back and forth, looked up to the ceiling, let out a deep breath, locked the medication cart and entered the resident's room. LPN #2 turned off the call light and exited the room. She told CNA #4, Resident #59 needed a blanket and she had told her the CNAs were busy and she needed to wait. CNA #4 said she would get a blanket for the resident when she was finished passing meal trays. On 4/12/22 at 8:01 p.m. Resident #59's call light had been activated for an unknown amount of time. Resident #59 was not yelling out. Upon entering the 200 unit nursing station, LPN #3 and CNA #1 were observed sitting at the nursing station. CNA #1 was scrolling on her phone and LPN #3 was on the computer. The call light board was lit up and making an audible beeping noise with Resident #59's room highlighted. When CNA #1 looked up from her phone, she put her cell phone in her pocket, walked out of the nursing station and entered Resident #59's room. D. Documented history of the resident's claustrophobia, wish to not have the door closed and dependence upon staff The activities of daily living care plan, initiated on 11/21/17 and revised on 12/30/21, revealed the resident had a self-care deficit related to weakness, [CONDITION(S)], obesity, a contracture to the hand, foot drop to both feet and the resident's hospice status. It indicated the resident required two person assistance with a Hoyer lift for transfers and the resident required care in pairs. The claustrophobia care plan, initiated on 1/21/21, documented the resident had reported to the nurse and executive director that she was claustrophobic. The interventions included do not close the resident's door unless it is for short periods of time to provide privacy during care. The anxiety care plan, initiated on 2/25/21 and revised on 6/14/21, documented the resident was at risk for anxiety. The resident would call out for help despite using the call light. She would request for tissues to be picked up off the floor and to move her water. The interventions included: re-educating the resident that sometimes staff cannot be there right at the scheduled time to assist the resident with care due to having to assist other residents. The verbal agitation and aggression care plan, initiated on 3/4/21, documented the resident calling out for help from the nurses or CNAs after activating the call light. It indicated the resident would continue to yell after the staff told her someone would be in to help. The resident was very particular and rigid on what time she wanted care to be provided. If the staff was not in her room at the designated times, then the resident would yell out for help until someone comes to provide care. The Kardex (a staff directive for care), undated, documented to leave the resident's door open at all times, except for privacy during care. If the resident requested to have her door shut when in the room by herself, get a witness to clarify the resident's request. E. Incident on 3/19/22 The 3/23/22 individual therapy notes documented the resident met with a psychologist. It indicated, in addition to being anxious the resident is claustrophobic. The Saturday night staff lost patience with her and shut her door. With the door shut, no one could hear her call for help. She felt the staff was punishing her. She felt she was suffocating, her heart was racing and thought she might die. Finally, the nurse came in and made sure she had the assistance she needed. The 3/23/22 nursing progress note documented the resident met with the psychologist. The resident reported that the staff shut her door on Saturday, 3/19/22. She said she felt this was done because the staff were punishing her. It indicated an investigation was started. The 3/23/22 abuse investigation revealed the resident reported to the director of nursing (DON) that her room door was closed on 3/19/22 by the facility staff. The resident said she was claustrophobic and did not want her door closed. The resident said she felt like the facility staff were punishing her. The resident statement documented, Saturday night was a nightmare for me. When I can ' t get anyone on the call light, I call out from my room and the staff does not like it so they closed the door which I think was to punish me. They say it's because my calling out disturbs other residents. But I ' m claustrophobic and I couldn ' t breathe. If I had my phone, I would have called 911 or the police because I panicked. Finally, a nurse came back approximately 30 minutes later but it felt like two hours. I don ' t report anyone unless I ' m fearful of them and I never want to see the staff member who closed the door on me ever again. The investigation documented the staff who worked on 3/19/22 were interviewed and said they had shut the door to the resident's room, but left it cracked because they were caring for another resident and Resident #59 was being disruptive and screaming out. It indicated all staff were educated to keep the resident's door open at all times unless they were providing care. The conclusion of the investigation documented neglect was unsubstantiated, the resident's care plan had been updated to keep the door open at all times unless providing care, a trauma assessment was completed and the resident would continue to have follow ups with social services. -However, based on the interviews with the staff documented in the investigation, the staff admitted to shutting the door to the resident's room and left it open a crack because she was disturbing other residents, which effectively secluded the resident against her will. The resident's wish of not having her door shut when she was by herself was well documented in the resident's medical record. F. Documentation of continued emotional distress from the incident on 3/19/22 The 3/24/22 social services progress note documented the SSC followed up with the resident who had reported a concern with her treatment by the facility staff. It indicated the resident frequently spoke of the incident on 3/19/22, appeared to still be distressed about what happened and appeared to still bother and affect the resident daily. The SSC indicated he ensured the resident's care plan indicated the resident's preference to never have her door shut, unless the staff were in the room providing care. The 3/24/22 trauma informed care evaluation revealed the incident on 3/19/22 was considered the worst event by the resident and the event that bothered her the most. It indicated the following: -The resident had quite a bit of episodes of disturbing and unwanted memories of the stressful experience; -The resident had episodes of suddenly feeling as though the stressful experience was happening again, as if she was reliving the incident; -Felt upset quite a bit when something reminded her of the incident; -Had quite a bit of strong physical reactions when something reminded her of the incident; -Avoided memories, thoughts, or feelings quite a bit related to the stressful experience and external reminders of the stressful experience; -Had quite a bit of negative beliefs about herself and negative feelings such as fear, horror, anger, guilt, or shame; and, - Felt super alert, watchful or on guard, jumpy or easily startled quite a bit. III. Staff interviews The SSC was interviewed on 4/11/22 at 4:47 p.m. He said he had worked at the facility since October 2021. He said he was the social worker for Resident #59. He said the resident was overall a very pleasant person. He said she would call out when she needed help after activating her call light. He said she had told him there was a history of the staff not answering her call light timely. He said she felt helpless because she was totally dependent upon staff, so if they did not answer her call light, she would not get what she needed. He said the resident did not like her door to be shut. He said she was claustrophobic and it had been documented in the resident's care plan. He said he had updated the resident's care plan after the incident, but the resident's wishes had been documented in the resident's care plan for over a year. He said he spoke with the resident about the incident that occurred on 3/19/22. He said the facility staff had closed her door when she was calling out for help. He said Resident #59 was claustrophobic and was shook up after the incident. He said the resident's impression was the staff were trying to punish her because she called out. He said he was not aware of the results of the investigation. Certified nurse aide (CNA) #3 was interviewed on 4/12/22 at 10:40 a.m. He said Resident #59 was totally dependent upon staff for assistance with all activities of daily living. He said she was not able to get out of the bed on her own without two person assistance and a mechanical lift. He said Resident #59 called out for assistance because she was afraid the call light would not be answered. He said she would call out for help even if the call light had only been activated for a minute. He said he thought this was because of a history of the staff not answering her call light timely. He said she did not like it when her door was closed unless someone was in the room with her. He said she was claustrophobic and had anxiety. He said Resident #59 wanting her door open was common knowledge and was not a new request by the resident. The NHA was interviewed on 4/12/22 at 4:44 p.m. She said Resident #59 had reported on 3/19/22 the night shift staff had shut her door because she was calling out for help. She said Resident #59 said she was claustrophobic and felt she was being punished by the facility staff for calling out for help. She said it was documented in the resident's chart for a long time that she did not want her door to be closed when someone else was not with her. She said the incident occurred on 3/19/22 and it was reported, by the resident, to the psychologist on 3/23/22. She said the facility conducted an investigation and reported the allegation of neglect to the State Agency. She said the SSA interviewed the resident and other nursing management interviewed the staff. She said she signed off on the final investigation. She said the investigation concluded the allegation of neglect was unsubstantiated because the staff did not have intent to harm the resident. She said she had not considered the potential of involuntary seclusion as a form of abuse from the incident. She confirmed in the interviews, the staff admitted to shutting the resident's door, but left it open a crack because she was disturbing other residents by calling out. She said she felt abuse was unsubstantiated because the staff did not intend to harm the resident. -However, the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident began to panic, screamed out for help and thought she was going to die.

Based on observations, interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part: -The facility failed to protect residents from COVID-19 as evidenced by not having an effective infection control program. Cross-reference F880 -The facility failed to monitor each contracted staff member' vaccination status to ensure proper advanced personal protective equipment (PPE) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. Cross-reference F888 -The facility failed to follow the Center for Disease Control (CDC) and the Centers for Medicare & Medicaid (CMS) guidance on staff testing for COVID-19. Cross-reference F886 -The facility had multiple systemic failures in its management of pressure injuries. These included the failure to timely assess and monitor for pressure injuries, prevent the development and worsening of pressure injuries for one resident. Cross-reference F686 These failures contributed to an environment where residents were at risk of contracting COVID-19 and worsening of pressure injuries. Findings include: I. Quality of care F686 Cross-reference F686. Facility administration failed to have a system/plan to ensure residents received care and services to prevent residents from developing facility acquired pressure injuries and worsening of pressure injuries. The facility failed to ensure thorough assessments and timely implement treatments to prevent pressure injuries from worsening. Interview The nursing home administrator (NHA) was interviewed on 4/14/22 at 3:18 p.m. The NHA said the facility was cited with a harm citation in December 2021. She said the corrective plan of care was to have another company oversee the pressure injuries. She said the other company came in on Tuesdays for weekly rounds and report in quality assurance. She said there was not an issue. She said the wound care rounds were a team effort. She was not aware if the contracted company was observing and overseeing all wounds or just the ones that the wound physician followed. II. Infection control A. F880 Cross-reference F880. Facility administration failed to ensure staff were engaged in safe practices while care for residents to ensure residents received the care and services required to maintain their highest practicable level of well-being. Interview The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said she was aware the facility had been in a COVID-19 outbreak since 12/23/21. She said the facility has had a lot of staff turnover and that a lot of agency staff was being utilized. She said the agency staff did not have a lot of training, and were less informed. She said the agency staff were also quitting. She said that she was aware the building had infection control breaks, however, she was not aware of the extent it was. She said masks had been a challenge the entire pandemic. She said when the administration was not in the building the staff became lax in mask wearing. She said she was not aware of the problems with handwashing, and complete PPE. She said the regional governing body came into the facility to assist, however did not develop a plan to get out of outbreak. B. F886 Cross-reference F886. Facility administration failed to ensure all staff were tested bi-weekly as required by CMS while the facility was in a COVID-19 outbreak since 12/23/21 to help prevent the spread of COVID-19 to residents. Interview The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said she was aware all staff did not testing. The label system was put into effect, which would show which staff member did not get tested they would be aware. She said the director of nurses was keeping her eye on the system. However, the DON was not effective and was not completing all aspects of her job. The nurse consultant came in to help the DON, however, the testing continued to be a problem and then the DON resigned effective immediately. C. F888 Cross-reference F888. Facility administration failed to monitor each contracted staff member's vaccination status to ensure proper advanced personal protective equipment (PPE) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. Interview The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said the corporation received the QSO updates (from CMS) and then sent them out to the facilities. She said she read them when she received them. She said did not understand what was needed with the policy changes and it was difficult to keep up with. She did not know what was expected for the F888 regulation. She said she believed attestations were ok to be used. She said she did not know that outside vendors such as physicians, volunteers and frequent visitors needed to have vaccination status on record and tracked. III. Additional interviews The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said she would be out of the building for the next ten days and unavailable for further interviews. The NHA said she had left the building and recently returned to the facility in February 2022. The NHA said she was told by the county that an outbreak was three individuals. She was not aware that CMS called an outbreak of one individual. She said nursing administration has had a lot of turnover. She said the facility hired a staff development coordinator however, she was terminated. The DON position had turned over several times within the year. She said the current DON had started in October or November 2021. Unit managers were also terminated as they were not effective. She said they could not find unit managers and were currently looking for a permanent DON. She said it was difficult to hire unit managers when the building did not have a DON. She said the biggest issue was the trust she had given the DON and she failed to carry out the job. The vice president of the region was interviewed on 4/19/22 at 3:50 p.m. The vice president said that she was aware there were concerns with the building, however, not to the level of immediate jeopardy. She said that the NHA reported to her and would be expected to hear of concerns from the NHA. She said the NHA and the DON were responsible for the management of the building.

Based on record review and interviews, the governing body failed to implement policies regarding the management and operations of the facility. Specifically, the facility failed to ensure the governing body was providing effective oversight to the facility to ensure the facility was in compliance with state and federal regulations. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) practice guide was received from the assistant nursing home administrator from a sister facility on 4/21/22. The policy read in pertinent part, The governing body assures the QAPI program is adequately resourced to conduct its work. This included designation one or more persons to be accountable for QAPI; developing leadership and facility-wide training on QAPI; and ensuring staff time, equipment and technical trainings as needed for QAPI. They are responsible for etablings policings to sustain the QAPI program despite changes in personnel turnover. The governing body and executive leadership are also responsible for setting expectations around safety, quality, rights, choice and respect by balancing both a culture of safety and a culture of resident centered rights and choice. The governing body ensures that while staff are held accountable, there exists an atmosphere in which staff are not punished for errors and do not fear retaliation for reporting quality concerns. Cross-reference F867-failed to reassess and provide timely intervention to address repeated concerns related to quality of life and quality of care. II. Identified failures A. Findings in the area of abuse and neglect - failure of the facility to prevent abuse. Cross reference F603 at a harm level. Facility administration failed to have a system to ensure residents were kept free from involuntary seclusion which resulted in psychosocial harm. B. Findings in the area of skin integrity-failure to prevent facility acquired pressure injuries. This deficiency was cited previously during an abbreviated survey 12/21/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Cross-reference F686. Facility administration failed to have a system/plan to ensure residents received care and services to prevent residents from developing facility acquired pressure injuries and worsening of pressure injuries. The facility failed to ensure thorough assessments and timely implement treatments to prevent pressure injuries from worsening.This citation was cited at immediate jeopardy. III. Findings in the area of infection control-failure to have a system to ensure an infection control program whereby residents were protected from COVID-19. The following citations were cited at immediate jeopardy. Cross-reference F880. Facility administration failed to ensure staff were engaged in safe practices while care for residents to ensure residents received the care and services required to maintain their highest practicable level of well-being. Cross-reference F886. Facility administration failed to ensure all staff were tested bi-weekly as required by Center for Medicare Services while the facility was in a COVID-19 outbreak since 12/23/21 to help prevent the spread of COVID-19 to residents. Cross-reference F888. Facility administration failed to monitor each contracted staff member's vaccination status to ensure proper advanced personal protective equipment (PPE) strategies (as indicated in the facility's policy and procedure) were used to prevent the spread of COVID-19. The assistant nursing home administrator (ANHA) from a sister facility was interviewed on 4/19/22 at approximately 1:30 p.m. She said the director of nurses (DON) was the person who was ultimately responsible for the infection control and skin integrity. A request to view the report from the clinical support registered nurse (RN) on the facility's findings, however, ANHA said a report was not written. The reports were only shared with the NHA and the DON. -However, the facility did not have a DON and the NHA was unavailable for an interview in regards to the clinical support RN. III. Leadership interviews A licensed nurse, who wished to remain anonymous, was interviewed on 4/12/22. The licensed nurse said the facility has had numerous changes in administration which included the director of nurses and the nursing home administrator. She said it made it difficult to receive direction and support. The nursing home administrator (NHA) was interviewed on 4/12/22 at approximately 1:30 p.m. The NHA said last week the DON had scheduled time off, however, she was informed the DON resigned the position effective immediately on 4/11/22. The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said she would be out of the building for the next ten days and unavailable for further interviews. The NHA said she had left the building and recently returned to the facility in February 2022. She said that she returned to the facility because of the vice president who was now over the region, she had a lot of respect for and wanted to work with her. She said the building had a lot of support and consultants from each department could be reached out to for assistance. She said the building had some restructuring when the two companies merged in either 2017 or 2018. She said the governing body was aware of the COVID-19 outbreak. She said they came to help with the outbreak but they did not help with the plan to get out of outbreak. The NHA said the other buildings within the company she worked for had a nurse practitioner (NP) for wound care. She said they had just extended an offer to a NP to be in charge of wounds. She said that having a NP for wound care depended on the regional director of the building. The interim director of nursing (IDON) was interviewed on 4/18/22 at 5:11 p.m. The IDON said she was a contracted registered nurse who was hired as a unit manager. However, when they no longer had a director of nurses, they offered her the contract position so she spoke to her agency and got the contract changed to the director of nurses. She said she had just started her contract on 4/11/22. The DON realized the facility had many care issues that needed attention. The DON acknowledged she had not yet been provided training on the corporate processes and was in the process of learning about the expectations of the corporate office. She said she received support from her agency company. The assistant nursing home administrator (ANHA) from a sister facility was interviewed on 4/19/22 at 9:34 a.m. The ANHA said she worked in another state for the corporation. She said she had not worked at the facility in the past. She was sent out to help the facility, as the current nursing home administrator (NHA) was out on leave. She said the governing body was structured in a way to have business office support, rehabilitation, social services, activities and clinical support. She said the quality assurance consultants were contracted for each region. She said the schedule was not set as to when the clinical support would visit, as it depended on the building and the request. She said the regional director supervised the NHA. She said there was an registered nurse (RN) who was assigned to the facility for clinical support. She was unable to answer when the clinical support RN came to the facility. The medical director (MD) was interviewed on 4/19/22 at 1:41 p.m. The MD said he had been the medical director for the facility for the past two years. He said that the facility had a change in corporations about two years ago. He said that the administration has overturned numerous times. He said he had not met with the vice president since she took over several months ago. He said it had been a while since he had met with the governing body, approximately three years. The request to speak with the clinical support RN was denied on 4/19/22 at 2:00 p.m. by the ANHA. She said the clinical support RN was a contractor and not employed by the facility and she could not answer questions. The vice president of the region was interviewed on 4/19/22 at 3:50 p.m. The vice president said that she recently assumed the position of vice present in January 2022. She said she was previously the regional director. She said since January 2022 she had been in the building every other week. She said that she was aware there were concerns with the building, however, not to the level of immediate jeopardy. She said that the NHA reported to her and would be expected to hear of concerns from the NHA. She said the NHA and the DON were responsible for the management of the building. She said the DON ran the nursing department and occasionally if there was an issue then the governing body would meet with the medical director. She said she was not sure if the regional clinical support would write a report detailing the findings. The report was only shared with the DON and NHA. She said the expectation was if there were problems, then the NHA would phone her as the vice president. She said she did not participate in the QA meetings. The interdisciplinary team participated in the QA meetings.

Based on staff, medical director interviews and record review, the facility failed to ensure all responsibilities of the medical director were effectively performed, which had the potential to affect all residents of the facility. Specifically the facility failed to ensure: -The medical director fulfilled his responsibility for providing the implementation of resident care policies or the coordination of medical care in the facility; and, -Facility wide training in infection control. Cross- reference: F686-Treatment and services to prevent/heal pressure ulcers, F880-Infection control, F886-Testing resident and staff, and F888-COVID-19 vaccination. Findings include: I. Medical directors agreement The medical director (MD) independent contract agreement was signed on 8/28/17. The Medical director's duties and responsibilities were received on 4/18/22 at 10:00 a.m. which read in pertinent parts: Medical director shall be responsible for the implementation of resident care policies and the coordination of medical care in the facility. Medical director's specific duties and responsibilities shall include the following: 1.Overall coordination, execution and monitoring of physician services. Maintain effective liaison with attending physicians, and provides clinical guidance and oversight regarding the implementation of patient care policies. 2. In conjunction with the professional staff and consultants of facility, medical director collaborates in the development and implementation of written policies, procedures, rules and regulations to govern the skilled nursing care and related medical and other health services provided at the Facility and shall review the facility's policies, procedures, rules and regulations on an annual basis. Medical director is responsible for seeing that these policies reflect an awareness of and provisions for meeting the current needs of the patients of the facility. 5. Medical director shall actively participate as a member of the Facility's quality improvement process. Participation shall include regular attendance at, and reporting to the facility quality assessment and assurance committee. Monthly quality assurance meetings may include topics such as infection control, pharmaceutical services, dental care, patient care policies . 8. Participate in in-service training programs as needed on request by facility . 12. Advise the nursing facility staff regarding communicable diseases, infection control and isolation procedures, and serve as a liaison with local health officials and public health agencies that have policies and programs that may affect the nursing facility's care and services to residents. II. Failures The facility was in the current outbreak of COVID-19 since 12/23/21. Cross reference F880 During the recertification survey on 4/19/22 the facility was cited for infection control at a L (immediate jeopardy) level. Cross reference F888 During the recertification survey on 4/19/22 the facility was cited for COVID-19 vaccination of facility staff at a L (immediate jeopardy) level. Cross reference F886 During the recertification survey on 4/19/22 the facility was cited for failure to COVID-19 test staff at a L (immediate jeopardy) level. Cross reference F686 Prevention of pressure ulcers During an abbreviated survey on 12/21/21, the facility was cited for prevention of pressure ulcers at a G (harm) level. During the recertification survey on 4/19/22 the facility was cited for prevention of pressure ulcers at a J (immediate jeopardy) level. III. Record review The facility was unable to provide any documentation which showed the medical director had been involved in the management and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] IV. Interview The medical director (MD) was interviewed on 4/13/22 at 1:41 p.m. The MD said he was aware the facility was in an outbreak for several months. He said that they told him what they were doing with infection control and can go to their website to view the policies. He said the administration had not asked for much advice. He said he came to the building at least monthly. He said he walked around the facility from time to time depending on the outbreak status. He said the last few times he was in the building he had not walked the building. He said when he did walk the building he looked for proper use of personal protective equipment (PPE). He said about three or four months ago when he walked the building there were no issues. He said when he was asked by the facility for education on infection control he would provide, however, he had not been asked for quite some time. He said the facility was a corporation and they had their policies they followed and he was not asked. He said he understands that he needed to be more involved in questioning the administration. The MD said that he was not aware the facility was not tracking all staff which included the contracted staff. He said he was aware the facility used a lot of agency staff as they had a turnover with staff including administration. The MD said he was not aware the facility was not testing the staff bi-weekly. He said he was aware the facility was in outbreak status for the the past several months. He said the facility was good about notifying him of the COVID-19 outbreak. He said he was not aware the facility was not testing all staff bi-weekly as required. He has also not observed how the testing was being conducted. The MD also said he had instructed to follow CDC guidance on testing, however, he was not sure if the facility had listened, as the facility was a corporation. He said he had not pushed the issue like he should have. The MD said he had been the medical director since 2007. He said he came to the building at least monthly. He said during the pandemic he had completed some of the meetings remotely. He said he attended the quality assurance meeting (QA) and the psych-pharmaceutical meetings. He said he did review policies, however, the facility was a corporation and that they had their own policies. He said the facility did not ask him for much stuff. He said the corporation was structured with their protocol and they tell him what they were doing. The nursing home administrator (NHA) was interviewed on 4/14/22 at 3:18 p.m. The NHA said the medical director was available for any questions. He participated in the quality assurance and the psych-pharmaceutical meeting. The medical director (MD) was interviewed again on 4/19/22 at 1:45 p.m. The MD said he was aware the facility received a directed plan of correction in December 2021 for the prevention of pressure injuries. He said he had not met with the hired consultant. He said a nurse practitioner had been hired to follow the wounds. However, he was not aware this nurse practitioner was hired as of 4/14/22. He said that he has not personally completed rounds on the wounds, as there were a lot of people rounding. He said he had not reached out to physicians about any concerns with the pressure ulcers.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life, quality of care and infection control. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Program policy, issue date February 2019, read in pertinent parts, Quality assurance (QA) is a process of meeting quality standards and assuring that care reaches an acceptable level. Traditionally, we have a set thresholds to comply with the regulations. QA is a reactive, retrospective effort to look at why there was a system failure. QA activities do improve quality, but efforts frequently end once the compliance or standard has been met. Performance improvement (PI) is a proactive continuous process intending to prevent or decrease the likelihood of problems by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent or systemic problems. II. Review of the facility's regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies and initiate a plan to correct F686 Prevention of Pressure Ulcers During a recertification survey on 12/21/21, prevention of pressure ulcers was cited at a G (harm) level. During the revisit survey on 12/21/21, the facility was cited again for prevention of pressure ulcers at a K (immediate jeopardy) level. III. Cross-referenced citations that were all cited at immediate jeopardy level Cross-reference F686. Facility administration failed to have a system/plan to ensure residents received care and services to prevent residents from developing facility acquired pressure injuries and worsening of pressure injuries. The facility failed to ensure thorough assessments and timely implement treatments to prevent pressure injuries from worsening. Cross-reference F880: The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent infections, including the development and transmission of COVID-19. Cross-reference F886. Facility administration failed to ensure all staff were tested bi-weekly as required by Center for Medicare Services while the facility was in a COVID-19 outbreak since 12/23/21 to help prevent the spread of COVID-19 to residents. IV. Interviews The nursing home administrator (NHA) was interviewed on 4/14/22 at 3:18 p.m. The NHA said the facility was cited with a harm citation in December 2021. She said the corrective plan of care was to have another company oversee the pressure injuries. She said the other company came in on Tuesdays for weekly rounds and reported in quality assurance. She said there was not an issue. She said the wound care rounds were a team effort. She was not aware if the contracted company was observing and overseeing all wounds or just the ones that the wound physician followed. The NHA said she was aware the facility had been in a COVID-19 outbreak since 12/23/21. She said the facility has had a lot of staff turnover and that a lot of agency staff was being utilized. She said the agency staff did not have a lot of training, and were less informed. She said the agency staff were also quitting. She said that she was aware the building had infection control breaks, however, she was not aware of the extent it was. She said masks had been a challenge the entire pandemic. She said when the administration was not in the building the staff became lax in mask wearing. She said she was not aware of the problems with handwashing, and complete personal protective equipment (PPE). She said the regional governing body came into the facility to assist, however did not develop a plan to get out of outbreak. The NHA said she was aware all staff did not testing. The label system was put into effect, which would show which staff member did not get tested they would be aware. She said the director of nurses was keeping her eye on the system. However, the DON was not effective and was not completing all aspects of her job. The nurse consultant came in to help the DON, however, the testing continued to be a problem and then the DON resigned effective immediately. The NHA was interviewed on 4/14/22 at 3:18 p.m. The NHA said the corporation received the QSO updates (from Centers of Medicare & Medicaid) and then sent them out to the facilities. She said she read them when she received them. She said she did not understand what was needed with the policy changes and it was difficult to keep up with. She did not know what was expected for the F888 regulation. She said she believed attestations were ok to be used. She said she did not know that outside vendors such as physicians, volunteers and frequent visitors needed to have vaccination status on record and tracked. The medical director (MD) was interviewed on 4/13/22 at 1:41 p.m. The MD said he attended the monthly quality assurance (QA) meetings. He said during the meetings, he would review rehospitalization s, infections and antibiotics. He said the NHA and the director of nurses run the meeting. He said he did not review specific pressure wounds, he would review overall numbers. He said the QA was run as a corporation and they informed him of any changes, such as the COVID-19 outbreak. However, the facility did not seek his guidance. He said he had not pushed as much as he could for him to be more involved in the QA meetings. The vice president of the region was interviewed on 4/19/22 at 3:50 p.m. The vice president said she had not participated in a QA meeting. The assistant nursing home administrator (ANHA) from a sister facility and a regional support nursing home administrator (SNHA) were interviewed on 4/19/22 at 4:16 p.m. The ANHA said the quality assurance (QA) committee met monthly. She said the interdisciplinary team, the medical director and the pharmacist were in attendance. The ANHA said she was from another facility and had not been involved with the QA at the facility. The ANHA said abuse was covered for patient protection and it was a focus area in the QA. She said that at each meeting the risk management reports were reviewed, which was where the abuse allegations were documented. She said the reports were reviewed to ensure a thorough abuse investigation was completed. The ANHA said a performance improvement plan was put into place when an action item had been identified.

Based on observations, record review, and interviews, the facility failed to provide care and services to prevent the development and worsening of pressure injuries for one (#1) of four residents reviewed out of eight sample residents. Specifically, the facility failed to identify, six deep tissue pressure injuries (DTPI), a pressure injury to Resident #1's penis from an indwelling catheter, a perianal wound, and a skin tear, which were only identified by the hospital staff once the resident was discharged to the hospital. The facility also failed to complete routine skin audits, and therefore did not identify and treat the six DTPI's and three additional wound injuries. Additionally, the facility knew the resident was at risk for skin breakdown. Resident #1 had an existing, facility acquired, chronic stage four pressure injury to his left inner ankle, and a new unstageable pressure injury to his outer ankle. Despite the facilities knowledge of the two existing wounds to Resident #1's left ankle, the facility failed to monitor Resident #1 for further skin breakdown, and therefore failed to implement treatment and further preventive measures for an additional eight areas of skin breakdown and one skin tear. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/,d+[DATE]/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on [DATE], pressure ulcer classification is as follows: Category/Stage I: Nonblanchable [CONDITION(S)] Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate at risk individuals (a heralding sign of risk). Category/Stage II: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape [CONDITION(S)], perineal [CONDITION(S)], maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage III: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making [CONDITION(S)] possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without [CONDITION(S)] or fluctuance) eschar on the heels serves as ' the body's natural (biological) cover ' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .), Cambridge Media: Osborne Park, Western Australia; 2014, from https://www.ehob.com/media/,d+[DATE]/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf ([DATE]), Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. II. Facility policy and procedure The Pressure Injury Prevention Pathway, revised 2013, was received from the nursing home administrator (NHA) on [DATE] at 11:27 a.m. The policy documented in pertinent part, If a pressure ulcer is identified .a comprehensive evaluation is completed and documented in the patient's clinical record .Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer. Weekly skin evaluations are completed by the licensed nurse for any other patient. Current or healed pressure ulcers-daily body audit. Skin evaluations are documented in the clinical record. III. Resident #1 A. Resident status Resident #1, age 77, was admitted on [DATE], and readmitted on [DATE]. According to the [DATE] computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) was not completed. On [DATE] at 10:10 p.m., a nurses note documented he was alert and oriented times four, and able to make his needs known. The MDS assessment further documented, Resident #1 required extensive two person assistance with bed mobility, transfers, dressing, and toileting. He required extensive one person assistance with personal hygiene. Resident #1 was at risk of pressure injuries, and had one stage three pressure injury. The assessment documented he had no other wounds or injuries. B. Record review and interviews On [DATE] at 7:17 p.m., the nurses notes documented in pertinent part, that Resident #1 had a scab to his left ankle with redness around it. The family and physician were notified. -The size or cause of the scab were not documented. The nurses notes on [DATE] at 5:48 a.m. documented in pertinent part, inner ankle have a small area with eschar. On [DATE], the nurses notes documented Resident #1's skin was dry and intact. On [DATE] the wound physician (WP) #1 documented, the wound to the left inner ankle was unstageable pressure injury, obscured full thickness skin and tissue loss .1.2 c.m. by 1.2 c.m., no depth, small amount of yellow drainage, wound bed 100% slough (dead tissue). The wound was debrided and had the same measurements, but with a depth of 0.1 c.m., subcutaneous tissue was removed. Alternating pressure mattress in place, offloading and nutritional supplements . Healing is expected to be delayed due to identified impaired mobility, incontinence, and the inevitable effect of aging. -It is unclear from the documentation if this is when the wound was classified as a stage three pressure injury. The WP records over the next seven months, until [DATE] were reviewed. The inner left ankle wound remained about the same, stage three, with measurements of 2.0 c.m. to 2.8 c.m.long, to 2.5 to 3 c.m. wide, with a depth of 0.1 c.m. The last measurements of the left inner ankle wound documented, by WP #2, on [DATE], stage three, 2.0 c.m. by 2.5 c.m. by 0.1 c.m. On [DATE] at 2:00 p.m.the nurses notes documented in pertinent part open area to outer ankle, measures 1.8 c.m x 1.8 c.m., scanty amount of serous and sluggish tissue noted .reported burning pain when pressure on affected area, called physician and got order for treatment . Resident said he will inform his daughter and son. -There was no documentation of the outer ankle wound on the wound physician report on [DATE]. The nurse practitioner (NP) documented on [DATE] at 1:38 p.m. in pertinent part, inner ankle wound approx. 2.5 c.m., periwound pink (sic), good viable tissue, inner wound with culture today. Right lower extremity (RLE) with ,d+[DATE]+ weeping [CONDITION(S)] .history of [CONDITION(S)] and poor circulation. -There was no documentation of an outer left ankle wound. The Braden skin risk assessment, dated [DATE], was reviewed. The resident was documented at risk for skin breakdown due to occasional moisture, chairfast, and friction and shearing. The [DATE] physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Foley catheter care every shift, ordered [DATE]; -Bilateral prevalor boots while in bed every shift, dated [DATE]; -[MEDICATION(S)] 0UNIT/GM apply to L foot topically, dated [DATE]; -Body audit every week, every day shift, fridays, ordered [DATE]; -[MEDICATION(S)] AcetonideCream 0.1 %, Apply to flank, back, shoulders, daily at bedtime, ordered [DATE]; -Wound Care: Left Inner ankle pressure stage three: Cleanse with NS (normal saline), pat dry, apply collagen, ag alginate to wound bed, cover with foam dressing, change every other day and prn (as needed), ordered [DATE]; -Wound care to left outer ankle wound: Clean with NS and pat dry, apply calcium alginate and cover with border dressing, change daily, ordered [DATE]; and, -Wound team consult for left outer ankle wound, ordered [DATE]. -There was no documentation in the progress notes or the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's risk for alteration in skin integrity care plan, initiated [DATE], six months after the development of the inner ankle wound, documented in pertinent part, At risk for alteration in skin integrity related to: impaired mobility, MS ([CONDITION(S)]), use of motorized wheelchair in his room and hallways. Resident with open area to left inner ankle. Resident likes sitting outside in in court yard in hot weather, decrease/minimize skin breakdown risks, administer treatment per physician orders, diet and supplements per physician order, elevate heels as able, encourage fluids, encourage to reposition as needed; use assistive devices as needed, observe skin condition with ADL(activities of daily living)care daily; report abnormalities, offer and apply sunscreen when outside in hot, sunny weather, pressure redistributing device on bed, prevalor boots bilateral feet when in bed, if resident allows, provide preventative skin care routine and prn (as needed), use pillows/positioning devices as needed. Resident #1 had a second care plan which documented, Resident has pressure ulcer to inner left ankle related to immobility, initiated [DATE], six months after the wound to the inner ankle developed. It documented in pertinent part, administer treatment per physician orders, APM (alternating pressure mattress), friction reducing transfer surface, incontinence management, pain evaluation prior to treatment, repositioning during ADLs, skin barrier. Resident #1 had a third care plan related to the wound on the outer ankle, titled, Open area at left outer ankle related to: stage three pressure injury, initiated [DATE]. It documented in pertinent part, administer treatment per physician orders, diet and supplements per physician orders, elevate heels as able, encourage and assist as needed to turn and reposition; use assistive devices as needed, pressure reducing surface on bed and wheelchair, prevalor boots in bed bilaterally. On [DATE] at 12:22 a.m., Resident #1 was sent to the hospital with a low blood pressure of ,d+[DATE] and ,d+[DATE]. The hospital admission record, titled, Wound Care Consult, dated [DATE] at 12:39 p.m. was reviewed. The following wounds were documented as present on admission to the hospital [DATE]: Left Medial (inner) Malleolus (ankle), Stage 4 Present on Admission (POA), measured 2.5 c.m. (length) by 3.5 c.m. (centimeters) (width), no depth, black eschar (dead tissue) necrotic, periwound (tissue on wound edges) edematous (swelling), erythematous (reddening), [CONDITION(S)] (rough), peeling skin; -Left lateral (outer) malleolus, unstageable pressure injury, POA, measured 1.5 c.m. by 3 c.m., no depth, back, eschar, necrotic, periwound edematous, erythematous, [CONDITION(S)], peeling skin; -Left heel deep tissue pressure injury (DTPI), POA, measured 0.8 c.m. by 1 c.m. blister intact, periwound edematous, erythematous, [CONDITION(S)], peeling skin; -Left lateral heel DTPI POA, 2 c.m. by 1.5 c.m., burgundy blister, periwound edematous, erythematous; -Left hip DTPI POA, 1.5 c.m. by 0.5 c.m., black, burgundy, non-blanching (persistent redness with applied pressure), red, intact. -Left first distal Toe, DTPI POA, 0.2 c.m. by 0.2 c.m., blister, burgundy, intact; -Left lateral first metatarsal head (toe), DTPI POA, 0.5 c.m. by 1 c.m., burgundy, red: -Right lower Back DTPI POA 11c.m. by 1 c.m., burgundy, intact red, non blanching; -Distal penis, device related (foley catheter) mucosal pressure injury, POA, 0.5 c.m. by 0.5 c.m., mucosal, full thickness, black, periwound edematous, erythematous foley catheter in place, due to the [CONDITION(S)] (opening on underside of penis), the catheter moves around in the meatus causing friction and partial thickness wounds and a mucosal pressure injury from the catheter. The wound is draining moderate amounts of purulent (thick, miky) drainage, the scrotum is denuded from the drainage from the meatus wound; -Right peri-anal wound, 0.6 c.m. by 0.6 c.m., no depth, black and pink and red. Wound is mostly intact and black with a small partial thickness opening. Etiology of the wound is unknown. -Skin tear to right shoulder, POA, 2 c.m. by 2.5 c.m. by 0.2 c.m. deep, dry, pink, partial thickness; -Wound team plan, initiating offloading measures, debridement of unstageable wounds, moist wound healing and moisture management of peri-anal wound and scrotum. The facility body audits (skin audits) for July, August and [DATE] were reviewed on the treatment administration record (TAR). The ,d+[DATE], ,d+[DATE], and [DATE] body audit were signed off the TAR with a number nine. The TAR legend was reviewed. The legend documented a number nine indicated to see nurses notes. The nurses notes were reviewed for ,d+[DATE], ,d+[DATE] and [DATE]. -There was no documentation regarding the resident's skin for these dates. There was no documented assessment of the resident's skin, head to toe, since [DATE], three weeks preceding his hospitalization on [DATE], when nine new wounds were found by the hospital. Additionally, the body audits were scheduled for weekly, not daily, as indicated in the facility policy for a resident with current pressure injuries. IV. Interviews Resident #1's family member was interviewed on [DATE] at 10:09 a.m., via telephone. He said Resident #1's first wound on his inner ankle developed from rubbing on the electric wheelchair according to his nurse in 2020. The family member said it was a bruise at first. He said the nurse told him Resident #1 had the same socks on for two days and when they were removed the bruise had become a wound. The family member said that wound never did heal. The family member said Resident #1 went to the hospital [DATE] with urosepsis and concerns with his catheter. He said at that time the hospital documented only the one wound to the left inner ankle. The family member said on [DATE], Resident #1 was put in isolation, by the facility, for a fever. He said Resident #1 was in isolation for three days or so. During that time, the family member said Resident #1 would text him with concerns that the facility was not repositioning him. The family said Resident #1 went to the hospital again on [DATE], at that time, the hospital assessed him and he had the two left ankle wounds, and nine additional wounds that the family was unaware of. The family member said Resident #1 was discharged from the facility to another long term care facility, where he later died of [CONDITION(S)] due to his wounds. V. Interviews and record review The interim director of nursing (IDON) was interviewed on [DATE] at 2:22 p.m. She said she was only aware of the two wounds Resident #1 had on his left ankle. She was not aware of the wounds listed above discovered by the hospital. She looked at her laptop computer and reviewed the residents body audits for August and [DATE] on the TAR and in the nursing progress notes. She said there was no documentation in the progress notes for the body audits on [DATE], [DATE], and [DATE]. She said there should have been a nurse note if they had done a head to toe body check. The IDON said the last skin assessment looked like it was on [DATE]. The IDON said because the skin assessments were not completed, that must be how the facility missed the additional wounds noted at the hospital on [DATE]. The IDON said the body checks include a head to toe skin assessment and should have been documented in the progress notes. She said the note should describe any wound, bruising or redness. The area should be measured and described in terms of color, odor and drainage. The IDON said if it was a new wound the physician should have been notified for orders and the responsible party. The IDON said the resident would then be out on alert charting. She said the unit manager or IDON would then review the alert charting to see if there were new identified wounds. She said there was no alert charting for the additional wounds discovered at the hospital for Resident #1. She said the primary physician could refer a resident to the wound physician, or the nursing staff can review a resident if for example a wound is not healing after two weeks. The IDON said the wound physician visits weekly. She said there was no facility wound nurse. The IDON said, one of the nurses would do rounds with the wound physician. She said the wound physician looked at only wounds identified by the facility, and did not do a head to toe skin assessment. The IDON said she did not know how the wound to the resident's left inner ankle began on [DATE], or how the wound to the outer ankle began on [DATE]. She said she would investigate. Certified nurse aide (CNA) #2 was interviewed on [DATE] at 9:00 a.m. She said she remembered Resident #1, but did not know how he got the wound on his left ankle. She said he only had one wound to the inner ankle. CNA #2 said he was on an air mattress and we used to put a pillow between his legs because they were contracted and blue boots on him. Licensed practical nurse (LPN) #1 was interviewed on [DATE] at 9:05 a.m. She said she remembered Resident #1. She said Resident #1 only had one wound that she knew of to the left inner ankle. She said she did not know how he got it. LPN #1 said Resident #1 would call the staff when he needed to be repositioned. She said he was also on an air mattress and wore pressure relieving boots. Licensed practical nurse (LPN) #2 was interviewed on [DATE] at 10:44 a.m. She said skin or body audits should be done weekly. She said a head to toe assessment of the skin is done. She said the nurse should have then signed it off the TAR and documented a note in the progress notes describing the skin, even if there were no concerns. She said if there were a new wound or a concern with an existing wound, the nurse should have written it on the alert charting board and notified the physician and responsible party. She said the nurse should have described the wounds in the progress notes including size, shape, color drainage and odor. Additionally, she said, the CNA, when they are giving a shower or bath, should fill out a skin sheet to document any skin concerns and give it to the nurse. Resident #1's CNA skin sheets for all showers and baths in August and [DATE] were requested from the IDON on [DATE] at 10:00 a.m. At 12:08 p.m. the IDON provided a document titled Skin Worksheet dated [DATE]. She said that was the only bath skin sheet she had. She said the facility had been using agency staff and therefore they may not have been filled out. She said she could not locate any others. The skin worksheet documented redness and sore to the groin area and left hip, and sore to the left heel. The [DATE] nurses notes were reviewed. There was no documentation related to a sore of the left hip. Wound physician (WP) #2 was interviewed via telephone on [DATE] at 11:11 a.m. He said Resident #1 had the inner ankle wound for over a year. He said it was a pressure injury, but had not healed due to the resident's arterial insufficiency and end stage MS. The WP #2 said Resident #1 wore boots to relieve pressure, but would frequently refuse the boots. He said due to his poor circulation he did not expect the wound to heal and thought it was unavoidable due to his arterial insufficiency and his fragile skin. He said he anticipated Resident #1's skin would break down really quick. WP #2 did not know if the resident had ever had any vascular studies done. WP #2 said he was not aware of any other wounds to Resident #1. The IDON was interviewed again on [DATE] at 11:15 a.m. She said the wound to the left inner ankle was classified as a stage 3 according to WP after it was debrided on [DATE]. -However, this was not documented. She did not have any vascular studies, except for a doppler study done on [DATE] of the left lower extremity to rule out a clot. The results were provided by the IDON. The document titled, Radiology Report, dated ,d+[DATE], documented in pertinent part, negative exam, no deep vein [CONDITION(S)] involving the left lower extremity veins. Additionally, the IDON said there was no investigation of the initial inner left ankle scab that occured on [DATE]. The NP was interviewed on [DATE] at 11:24 a.m. She said Resident #1 had poor circulation and end stage MS. She said she did not anticipate his left inner ankle wound would heal and was most likely unavoidable. The NP said he had a newer wound to his left outer ankle. She said Resident #1 was alert and oriented and very involved in his own care. She did not know how the ankle wounds occurred. The NP said she was not aware of any further wounds as observed and documented by the hospital on [DATE]. She said he had pressure relieving interventions in place, and he wore bunny boots when she saw him. The NP looked at her laptop and said she did not see any vascular studies for Resident #1 in her records.

Based on observations, record review and interviews, the facility failed to ensure effective fall interventions were in place to prevent resident falls for six (#96, #21, #18, #15, #39 and #35) of 10 residents reviewed for falls out of 58 sample residents. Resident #96 had a history of [REDACTED]. The resident was living in an assisted living facility but moved to the long-term care facility because she was having frequent falls and required a higher level of care. The facility was aware of the resident's condition and health status upon initial admission on 6/22/19. Progress notes revealed the resident was experiencing increased confusion, decreased safety awareness and needed a reminder to ask for assistance. The care-planned interventions included increased monitoring and to check in with the resident to assess for unmet needs including for toileting assistance. Facility records failed to show post fall investigations for patterns in resident's fall history or assessment of the care plan interventions for effectiveness. On 10/8/2020, the resident was found on the floor in her bathroom after having an unwitnessed fall. A nurse assessed her to have pain in her right wrist and hip and a decrease in range of motion ability with a visual deformity to her right lower extremities (see record review notes below). Hospital notes dated 10/9/2020 revealed the resident had a fall the day prior to being admitted to the hospital which resulted in a closed fracture of neck of right femur, requiring surgical intervention; a closed fracture of right distal radius, requiring manipulation and splinting and a closed fracture of right wrist, requiring splinting. The facility failed to effectively assess, develop and implement care-planned interventions to prevent a fall where the resident sustained [REDACTED]. Resident #21 had a history of [REDACTED]. The facility was aware of the resident's fall risk upon admission. The resident's medical record revealed the resident had a [DIAGNOSES REDACTED]. The resident often refused to request assistance or failed to request assistance. The resident needed extensive assistance with all activities of daily living particularly with transfers, toileting needs and bed mobility. The care planned interventions included for staff to provide the resident frequent rounding for toileting needs, assist for transfer from surface to surface and assistance when standing to walk. There was no documentation that the resident refused care assistance as it was provided. While it was documented that the resident refused to request assistance; there were no documented notes to show the resident ability to use the call light was assessed or that other methods of requesting staff assistance were pursued. The resident had four unwitnessed falls from 11/28/2020 to 1/15/21. On 11/28/2020, the residents fall resulted in a serious injury requiring the resident to get three sutures to the forehead and surgical intervention for a [MEDICAL CONDITION] and splinting and medical manipulation for a fractured wrist. The fall on 12/1/2020 occurred as the resident was going to the bathroom unassisted and the falls on 12/26/2020 and 1/15/21 occurred just prior to the certified nurse aide (CNA) arriving to assist the resident to bed. The facility failed to effectively assess, reassess and implement care-planned interventions to prevent a fall where the resident sustained [REDACTED]. Resident #18 had a history of [REDACTED]. The initial care plan intervention for Resident #18 who was assessed to be independent with all activities of daily living including walking, but had poor balance and intermittent confusion related to [DIAGNOSES REDACTED]. Since initial admission, the resident fell 10 times while in the care of the facility. There were several fall events where the facility was unable to show documentation of a post fall investigation to assess cause of the fall, or identify newly developed resident care needs for the purpose of minimizing and preventing falls. The resident most recent documented fall history showed the resident had several self-reported falls after experiencing increased pain from falling. The most recent fall resulted in the resident sustaining a major injury. On 12/30/2020, the resident was found on the floor in her room, initial nursing assessment noted no injuries. Six hours later the resident complained of discomfort in her left hip. The resident was unable to bear weight and was wincing in pain. Mobile x-ray revealed the resident sustained [REDACTED]. The facility failed to consistently and effectively assess, reassess and implement care-planned interventions to prevent a fall where the resident sustained [REDACTED]. Resident #35 had a history of [REDACTED].#35's initial admission on 6/15/18, she had a history of [REDACTED]. The resident experienced two falls, 8/22/2020, 9/13/2020, in the two months prior to the most recent fall of 10/7/2020. The care plan intervention, initiated 1/28/2020, directed extensive assistance of two staff for toileting.The most recent fall occurred when the resident was in the bathroom on 10/7/2020, where the resident was transferred to the hospital resulting in a left femur fracture and head and left shoulder injuries. As a result, hospice care and services were ordered on [DATE] for a non-operative femur fracture and pain management. Resident #15 sustained a hand injury during a transfer with a mechanical lift in June 2019. The physician ordered an x-ray which revealed soft tissue injury without fracture. The facility failed to investigate the cause of the incident and to identify any hazards or risks to reduce the risk of injury occurring again. Additionally, the facility failed to implement effective fall interventions for Resident #39 with a history of falls and poor upper body strength. Findings included: I. Facility policy The facility's fall prevention policy was requested on 1/21/21 at 9:14 a.m., to the interim director of nursing (IDON). The policy was not provided. The IDON provided a document titled Fall Practice Guide Flowchart'', on 1/21/21 at 10:33 a.m. The IDON said this is the document the policy the facility follows to address fall management. The Falls Prevention Guide, issued December 2011, was provided by the nursing home administration (NHA) on 1/29/21 at 12:25 p.m. It read in pertinent part: The information included within this guide does not relieve a business unit/facility of the obligation to comply with all applicable corporate policies as well as federal and state regulations. -Fall management focuses on minimizing fall risk factors and fall related injuries while continuing to promote the patient's quality of life. -Of the elderly who fall, 20 percent to 30 percent suffer moderate to severe injuries such as [MEDICAL CONDITION] or head traumas that reduce mobility and independence, and increase the risk of premature death. -If, upon completion of the patient admission/readmission screen, the patient is found to be at risk for falls or has a history of falls, the physician is contacted for orders, as appropriate -The interdisciplinary team designs the patient's care plan to focus on all of the patient's issues including those associated with fall prevention and fall risk management. -Patient falls are tracked by time, location and causative factors. The data is reviewed to identify any trends. The results are submitted to the QAA Committee for review and recommendations, as indicated. The Falls Practice Guide is intended to assist clinicians with the overall identification and management of patients at risk for falls. The falls incident report packet was provided on 1/19/21 at 8:45 a.m. by the NHA, the packet revealed the post fall investigative process steps. The instructions reading part: This report is prepared for purposes of quality assurance . -The fall investigation gathered specific data in order to investigate the fall and determine appropriate actions. Gathered data including a description of the fall event with the date, time and location of the fall, type of fall and injury, if any; any medical devices used by the resident; physician and responsible party notification; and facility action related to resident care; -Once the initial data was gathered the investigator made a statement containing all information, analysis and data collected for further review by the quality assessment and assurance committee. The investigative data gathered was for the purpose of quality assurance purposes; -Findings included immediate actions, IDT (interdisciplinary team) review recommendations, and IDT follow up. -Nursing staff were to document the fall in the resident's record and complete a post fall assessment, pain assessment, continence assessment, skin assessment, update the care plan, keep the resident on alert charting and complete a five day fall note documenting the resident's status and condition. II. Resident #96 A. Resident status Resident #96, over the age 85, admitted on [DATE]. The resident passed away and was discharged from the facility on 11/6/2020. According to the November 2020 computerized physician's orders [REDACTED]. Repeated falls was listed as an admission diagnosis. The 9/4/2020 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident used a wheelchair mobility device and needed extensive assistance with one staff providing weight bearing and balancing assistance with transferring from seated to a standing position and from surface to surface; bed mobility; toilet assistance for all steps in the process of going to the bathroom; and dressing. The resident needed limited assistance from one staff to walk once steady and in a standing position. The resident was frequently incontinent of both bowel and bladder but a trial of a toileting had not been attempted. The resident was not receiving any physical or occupational therapy and was not on a restorative nursing program. B. Record review 1. Care plans The care plan initiated 6/22/19 revealed the resident was at risk for falls due to weakness, confusion, recent fall and fractures; with a goal to minimize risk for falls. Care planned interventions included frequent checks for unmet needs- offer to take to the bathroom each check; reinforce the need to call for assistance; encourage to transfer and change positions slowly; have commonly used articles within easy reach. -The resident required assistance for transferring from one position to another, with the goal to attain/maintain the ability to transfer self safely. Care planned interventions included: use gait belt to facilitate safe transfer. -The resident had urinary incontinence related to bladder muscle weakness and impaired mobility. Care planned interventions included: adjust toileting times to meet patient needs; and provide assistance with toileting. The care plan was not updated or reviewed for effectiveness and did not include a toileting trial to improve continence until the resident had a fall with major injury. 2. Progress notes and assessments The resident's medical record revealed the following progress notes and assessments: -Mood/behavior nursing note dated 7/8/2020 at 7:08 p.m., read: Resident continues to ambulate ad lib in hallways. Resident was extremely confused and often wandered in/out of other resident's rooms. Resident continues to ask where do I go? Resident was easily re-directed by assisting back to the television room or her room. Continue to monitor. -Medical practitioner (physician/NP) physician services note dated 7/26/2020 at 3:25 p.m. read in part: resident was living with family, but it became too difficult. Moved into an assisted living facility, but is requiring a higher level of care due to recurrent falls. -Care plan progress note dated 9/14/2020 11:58 a.m., read in part: Resident triggered to consider a significant change of status on this MDS for decline in transfers, eating, and bowel incontinence. She was needing one staff for supervised transfers and at this time needing one staff and extensive assistance . - General progress nursing note dated 10/8/2020 1:11 p.m., read: At 12:00 p.m., CNA entered the resident's room and found her sitting on the floor in front of the bathroom complaining that her hand hurt. She was wearing non-skid socks, a blouse and pull ups with no pants on. Resident could not report what had happened. A RN assessed and noted the resident's right leg appears shorter than the left leg and the resident was complaining of pain to the right hip as well as right hand and wrist. The resident had decreased range of motion (ROM) to the right upper and lower extremity. The unit manager reported the incident to the resident's physician and got orders for x-rays. The resident's daughter was notified by phone. Neurologic and vital signs were within normal limits. Resident put on fall follow up protocol. -Fall assessment dated [DATE] at 1:32 p.m., revealed: the Resident had a fall on 10/8/2020 at 12:00 p.m. Conditions included low levels of physical activity; impulsivity or poor safety awareness; cognitive impairment; incontinence; wandering and agitation. There were no associated environmental factors and the care plan was not revised. -General progress nursing note dated 10/9/2020 at 4:00 a.m., read in part: X-ray results: .shows right wrist distal radial fracture, mild soft tissue swelling; right [MEDICAL CONDITION]. Results called in to the physician. -General progress nursing note dated 10/9/2020 at 6:15 a.m., read in part: .New order received to send resident out to the emergency room for evaluation and treatment. -Medical practitioner (physician/NP) physician services note dated 10/15/2020 at 12:38 p.m. read in part: consult: chief complaint: Pain and rehabilitation needs secondary to fall causing acute displaced right femoral neck fracture, s/p (status [REDACTED]. -Hospital treatment records dated 10/9/2020 at 1:17 p.m., revealed the resident was admitted on [DATE] after a fall the day prior on 10/8/2020. The resident was experiencing right hip and wrist pain. Following assessment, the resident was diagnosed with [REDACTED]. The assessment and treatment plan documented that the resident was to admit to the hospital trauma unit for pain control and follow up with orthopedic surgery and hospitalist consultations. -Hospital progress note dated 10/11/2020 at 12:48 p.m. revealed the resident's final [DIAGNOSES REDACTED]. The resident was two days in post-op for a right hip replacement and right wrist manipulation and splinting. The treatment plan orders revealed the resident required pain control and staffing assistance for activities of daily living. The resident remained a very high fall risk requiring three to four people to move to the edge of bed. Medical recommendations read: Given the resident's age and degree of dementia and apparently extreme fall risk if returning to the facility under previous conditions, the patient will be better served by staying in hospital for further discussion with palliative care team tomorrow about goals of care and options to additional hospitalization s. C. Interviews The resident was unavailable for interview and observation as she passed away on 11/6/2020. Unit manager (UM) #1 was interviewed on 1/21/21 at 2:41 p.m. UM #1 said the resident was in a state of cognitive decline prior to falling. Resident #96 had poor safety awareness, was confused, and needed staff assistance with toileting. Since the resident was not good about using her call light staff were to anticipate the resident's needs and check on her frequently, to see if she needed anything. Although not on a toileting schedule, staff were to offer to take the resident to the bathroom frequently, every couple of hours or more if she declined an offer to use the bathroom. After reviewing the resident's medical record the UM #1 said she remembered the resident's fall on 10/8/2020, and said the resident must have gotten up to use the bathroom, but she was not sure if the resident was on her way to or back from the bathroom when she fell and was discovered after falling on 10/8/2020. III. Resident #21 A. Resident status Resident #21, age 84, admitted on [DATE]. According to the January 2021 CPO, [DIAGNOSES REDACTED]. The 10/28/2020 MDS assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of six out of 15. The resident used a wheelchair mobility device and needed extensive assistance of two staff providing weight bearing and balancing assistance with transferring from seated to a standing position and from surface to surface; bed mobility; toilet assistance for all steps in the process of going to the bathroom; and dressing. The resident needed limited assistance from two staff to walk on the unit once steady and in a standing position. The resident was frequently incontinent of both bowel and bladder but a trial of a toileting had not been attempted. The resident was not receiving any physical or occupational therapy and was not on a restorative nursing program. B. Record review 1. Fall history -On 11/28/2020 at 2:41 p.m., the resident was found on the floor of her room after having an unwitnessed fall. The resident sustained [REDACTED]. -On 12/1/2020 at 10:10 a.m., the resident was found on the bathroom floor next to the toilet after having an unwitnessed fall with no additional injuries. -On 12/26/2020 at 10:26 p.m., the resident was found on the floor next to the roommates bed, after having an unwitnessed fall, just before a CNA arrived to assist her to be. The resident sustained [REDACTED]. -On 1/15/21 at 8:15 p.m., the resident was found on the floor at bedside, just before the CNA arrived to assist the resident to bed. The resident had an unwitnessed fall without further injury. 2. Care plan The care plan initiated 7/2/19 revealed the resident was at risk for falls due to unsteady gait and poor safety awareness, impulsivity and refusal to request assistance; with a goal to minimize risk for falls. Care planned interventions last revised on 12/27/2020 included: -Anti tip device added to resident's wheelchair, initiated 9/21/2020. -Encourage resident to wear closed heel shoes, imitated 2/5/2020 -Encourage the resident to transfer and change positions slowly, initiated 7/2/2020. -Evaluate medications if the patient demonstrates changes in mental status, ADL function, appetite, neurological status, etc., initiated 11/28/2020. -Frequent rounding for toileting needs, initiated 1/15/2020. -Have commonly used articles within easy reach, initiated 7/22/19. -Keep bed at transfer height at all times, initiated: 3/10/2020. -Offer wheelchair as resident allows, initiated: 12/16/19. -Provide assistance to transfer and ambulate as she allows, initiated: 2/10/2020. -Reinforce need to call for assistance, initiated: 7/2/19. -Reinforce walker safety, as needed such as locking brakes, initiated: 12/16/19. -Remind the resident to use prescribed assistive devices during ambulation for safety, initiated: 7/20/2020. -Report development of pain, bruises, change in mental status, ADL function, appetite, or neurological status per facility guidelines post fall, initiated: 8/5/2020. -Requested Labs and medication review, Initiated: 12/7/2020. -Wheelchair cushion for wheelchair positioning, initiated 9/21/2020. 3. Progress notes and assessments The resident's medical record revealed the following progress notes and assessments: -General nursing progress note dated 11/28/2020 at 2:41 p.m. read: CNA notified this nurse that the resident is on the floor. Upon arrival the resident's room the resident was sitting on the floor, with legs extended. Resident was bleeding from the left side of the forehead, noted deep laceration two (2) centimeters (CM) by one (1) CM by two (2) CM, bleeding ceased with compression. Resident stated she missed the chair and fell forward and hit her forehead on the floor. Notified the on call physician by phone, received an order to send the resident to the emergency room for sutures. Swelling noted on the resident's left wrist, the resident complained of mild pain rating a two out of 10. Transport called. -Medication Administration Record [REDACTED]. Tylenol Tablet, 650 milligram (MG), for pain with positive results by 4:14 p.m., but the pain scale was still rated as two out of 10. -Fall assessment dated [DATE] at 5:59 p.m., revealed the resident had physical performance limitations evidenced by impaired balance during transitions, arthritis, agitation and depression. There were no associated environmental factors. -General nursing progress note dated 11/28/2020 6:35 p.m., revealed the transport provider arrived to take the resident to the emergency room for an assessment. -General nursing progress note dated 11/28/2020 8:21 p.m., read; The hospital called to update on the resident's condition. Sutures to the left side of forehead and resident with a fracture to the left arm and will come back in a splint with instructions to follow up with an orthopedic doctor. -General nursing progress note dated 11/28/2020 11:19 p.m., read; Resident returned to facility by transport from the hospital. Resident remains at her normal baseline. Resident has a dressing to the left forehead and a splint on the entire left arm with a sling . -An interdisciplinary team (IDT) review note dated 11/30/2020, signed by UM #1 read: encourage to ask for assistance. -General nursing note dated 12/1/2020 at 10:10 a.m. read; The resident was found sitting up on the floor of the bathroom next to the toilet. Assisted resident to the toilet. Neurologic, vital sign and ROM (range of motion) checked and were within normal limits. Skin assessed, no new alterations noted. Physician notified by phone. -Fall assessment dated [DATE] at 11:02 a.m., revealed the resident had physical performance limitations evidenced by impaired balance during transitions difficulty maintaining standing position, dementia and depression. There were no associated environmental factors. - Medical practitioner (physician/NP) physician services note dated 12/1/2020 at 3:54 p.m., read in part; Acute visit: chief complaint- resident had a recent fall and was seen in the emergency room with left upper extremity closed supracondylar [MEDICAL CONDITION] (elbow) and laceration to the left side of the forehead. Patient had another fall this morning .sutures in place to left forehead. Assessment and Plan .sutures to be removed on 12/5/2020. Follow up with the orthopedic physician on/around 12/5/2020. Patient is confused at baseline and has poor safety awareness, and continues to be impulsive .continue supportive long term care . -Care plan progress note dated 12/3/2020 at 10:34 a.m., read; Five day fall management meeting to review the residents incident from 11/28/2020 - Care plan reviewed and revised to include encouraging the resident to call for assistance. -Care plan progress note dated 12/7/2020 at 10:34 a.m., read; Five day fall management meeting to review the resident's incident from 12/1/2020. The care plan was reviewed and revised to include request Labs and medication review. There was no other documentation of assessment of current care planned intervention or of the current care plan effectiveness. The resident required two staff assistance with transfers, as indicated by the resident's care plan and 10/28/2020 MDS. -General nursing note dated 12/26/2020 at 10:20 p.m., read; CNA went in to help resident to bed and found resident on the floor by her roommates bed with her wheelchair behind her. Resident has several skin alterations on forehead, upper forehead measuring two (2) CM by one (1) CM, under that and between the eyebrows measuring one (1) CM by one (1) CM and a small skin scrape to the left temporal area. Resident states she does not remember what happened. Resident was in a wheelchair then found herself on the floor. On assessment, no other injuries noted at this time. No loss of consciousness. Staff assisted the resident back to the wheelchair and then into bed. Skin alterations cleaned and steri-strips applied. -Fall assessment dated [DATE] at 10:25 p.m., revealed the resident had physical performance limitations evidenced by impaired balance during transitions, decline in functional status, incontinence, muscle weakness, antidepressants, narcotic [MEDICATION NAME], visual impairment, hearing impairment, dizziness/[MEDICAL CONDITION], impulsivity or poor safety awareness, agitation, cognitive impairment, depression, low levels of physical activity, pain, fatigue and weakness. There were no associated environmental factors. -An interdisciplinary team (IDT) review note dated 12/28/2020, signed by UM #1 read; interventions in place. and the interventions were not listed There was no documentation of a five-day fall management meeting documenting an assessment of current care planned intervention or of the current care plan effectiveness. -General nursing progress note dated 1/15/21at 8:15 p.m., read; CNA went to resident's room to put her to bed and resident was on the floor lying on her right side between her bed and her wheelchair. Resident was unable to state what happened. On assessment, no injuries noted at this time. Resident has no complaints of pain. ROM and neurologic checks were within normal limits for the resident. Resident was assisted to bed. -Fall assessment dated [DATE] at 8:13 p.m., revealed the resident had difficulty maintaining sitting balance; difficulty maintaining standing position; impaired balance during transitions; and need to rock body or push off on arms of chair when standing up from chair. Medication potentially affecting resident's condition included antidepressant use, cardiovascular medications and narcotic [MEDICATION NAME]. Associated health conditions included: decline in functional status; incontinence; wandering; agitation; cognitive impairment; dementia; depression; muscle weakness; joint pain; other pain; fatigue and weakness. There were no associated environmental factors. C. Resident interview and observations On 1/14/21 at 3:15 p.m., Resident #21 was observed sitting up in bed. The bed was a medium height. She was unable to operate the call light even with prompts. The call light was pointed out but the resident was not able to place the call light that was in view and in reach on the bed, beside her and a top of her blankets. Resident #21 was interviewed on 1/19/21 at 10:50 a.m. The resident was observed sitting in bed and was attempting to reach for her water cup which was placed on the over the bed able table. The table and cup were out of her reach by several inches; no matter how far she reached forward and struggled to grasp the table and cup she was unable. The resident said I'm trying to get my cup. Resident #21 was not able to use her call light to call for staff assistance despite the call light being in reach and verbal prompting guiding her on how to use the call light. When asked the resident was not able to answer specific questions about the documented fall episodes, but began rubbing her wrist, grimacing and whimpering then said, it hurts all the time. When asking for further clarification about her pain the resident said, I'm dopy while pointing to her head and my back hurts. The nurse was alerted of the resident's pain complaints and arrived to assess and treat the resident pain complaint. D. Staff interviews Licensed practical nurse (LPN) #6 was interviewed on 1/19/21 at 10:58 a.m. LPN #6 said the resident had recent fractures after falling and was still having pain. The pain was usually resolved after administering the resident as needed [MEDICATION NAME] (pain) medication. The LPN confirmed the resident was cooperative with cares but needed a calming reassuring approach. At baseline, the resident had a sad and weepy affect. The LPN said the resident was not likely to ask for help on her own so staff had to check on her frequently and anticipate her needs. They kept the bed a height for transfers and encouraged her to wear non-slip socks while in bed, in case the resident tried to get out of bed on her own. The LPN explained the fall reporting process was for a registered nurse to assess the resident's condition and report findings to the director of nursing. The IDT would review the post fall investigative data, assess the resident's condition and the care plan was to be updated with any new interventions. Care plans were updated by the unit managers, but the floor nurse could also add to the care plan if additional interventions needed to be added. Certified nursing aide (CNA) #18 was interviewed on 1/19/21 at 1:10 p.m. CNA #18 said she would usually check on the Resident #21 at least every hour and look in on her from the hall in between check ins to see if the resident needed anything. Unit manager (UM) #1 was interviewed on 1/21/21 at 2:41 p.m. UM #1 said Resident #21 was reluctant to ask for help. Staff were expected to check on the resident every couple of hours to see if she needed any assistance and encourage the resident to use the bathroom during the check in. If the resident declined and had not used the bathroom recently the staff were to return to the resident room a little bit later, for example after checking on and helping another resident because the resident may get the urge to use the bathroom after the initial offer for assistance. Resident #21 could be impulsive and was used to doing things for herself. Because of declining cognition, the resident did not make good decisions and had poor safety awareness. IV. Resident #18 A. Resident status Resident #18, age 76, admitted on [DATE]. According to the January 2021 CPO, [DIAGNOSES REDACTED]. The 10/21/2020 MDS assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 15 out of 15. The resident used a wheelchair or walking mobility device and needed extensive assistance of two staff providing weight bearing and balancing assistance with transferring from seated to a standing position and from surface to surface; bed mobility; toilet assistance for all steps in the process of going to the bathroom; and dressing. The resident needed supervision and physical assistance by one staff while walking to stabilize once steady and in a standing position the resident (T

Based on record observations, recore review and interviews, the facility failed to ensure four (#78, #81, #15 and #70) residents out of 58 sample residents received care to prevent pressure ulcers and did not develop avoidable pressure ulcers; and residents with pressure ulcers received necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The facility failed to ensure Resident #78, who was at high risk for skin breakdown and required extensive assistance from staff for most activities of daily living, did not develop avoidable pressure ulcers. Moreover, the facility failed to accurately document a pressure injury and ensured preventive measures were in place. Due to the facility's failures, the resident sustained [REDACTED]. In addition, the facility failed to: -Prevent Resident #81 from a pressure ulcer worsening acquired by the facility; -Provide an incontinence schedule, encourage position changes and assess and document alterations in Resident #15's skin; and; -Ensure Resident #70, who had pressure injuries, was positioned timely. Findings include: I. Professional references According to NPIAP (National Pressure Injury Advisory Panel), (last updated 3/21/2020) retrieved on 2/9/21 from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages revealed the following: Intervene to reduce risk, surfaces to reduce intensity of pressure and shear include turning and repositioning to reduce duration of pressure and shear, keep skin clean and dry, provide adequate protein, calories, and fluids, and using [MEDICATION NAME] dressings. Choose interventions based on subscale level of Braden scale. Apply barrier cream on the skin that contains dimethicone or zinc oxide or [MEDICATION NAME]. According to NPIAP (National Pressure Injury Advisory Panel) Stages (last updated 2016) retrieved on 2/9/21 from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages revealed the following pertinent information: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. -A stage 2 pressure injury is partial-thickness skin loss with exposed dermis. The National Pressure Injury Advisory Panel (last updated 2016) Pressure Injury Stages, retrieved on 2/9/21 from: http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf revealed interventions for prevention and treatment of [REDACTED]. -Assess the pressure ulcer initially and re-assess it at least weekly. Signs of deterioration (e.g., increase in wound dimensions, change in tissue quality, increase in wound exudate or other signs of clinical infection) should be addressed immediately. -Assess and document physical characteristics including: location, Category/Stage, size, tissue type(s), color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate, and odor. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. -Scheduled repositioning should be done to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time; -Heels should be placed in a position that eliminates pressure, referred to as floating the heels, by placing a cushion under the full back of the resident's calf. II. Facility policy The Skin Practice Guide Process Flowchart Policy, last revised 2013, was received by the interim director of nursing (IDON) on 1/19/21 at 5:45 p.m. It read in pertinent part to, residents are assessed with [REDACTED]. If a resident has a current or healed pressure injury, a daily body audit is required and a care plan for other specific resident risk factors identified. III. Resident #78 A. Resident status Resident #78, over [AGE] years of age, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 9/17/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of six out of 15. She required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. She required supervision when eating. She was not able to walk. She did not have pressure injuries with a risk to develop pressure injuries. B. Observations On 1/12/21 at approximately 5:30 p.m., the residnet was lying in bed eating her meal. The resident's heels were directly on the mattress, with no pillow or cushioned boot to relief pressure. On 1/14/21 at 1:33 p.m., the resident was sitting in her wheelchair. The resident had socks on her feet. Her feet were directly on the floor. On 1/18/21 at 5:30 p.m., the resident was laying in bed awaiting her evening meal. The resident's heels were directly on the mattress, with no pillow or cushioned boot to relief pressure. On 1/19/21 at 9:49 a.m., the resident was laying in bed on her back with both her right and left heel directly on the bed. There were no devices or protection to relieve pressure for her heels. On 1/19/21 at 10:50 a.m, Resident #78 laid in bed on her back with her heel directly on the bed, there were no devices or protection to relieve pressure for her heels in place. On 1/19/21 at 10:55 a.m., registered nurse (RN) #5 provided wound care to Resident #78. The sock was off of the resident's foot and exposed a black area on her heel 4.2cm x 3.1cm x 0.1cm comparable to the size of an egg. It was oozing a small amount of red and clear fluid, without an odor. She painted the ordered ointment on the wound bed that was black. C. Record review Resident #78's admission assessment was completed on 12/28/2020 and revealed the resident did not have any skin problems on admission to the facility and it read the resident's heels, and coccyx were clean, dry and intact. The 1/7/21 Braden risk assessment tool revealed Resident #78 was at high risk for skin breakdown, with risk factors of very limited mobility and being chairfast. The care plan last updated on 1/12/21 identified the resident was at risk for skin breakdown. Pertinent interventions included to provide preventative skin care routinely and as needed, encouraged repositioning as needed and report changes to skin integrity. A new focus area on her care plan was created on 1/12/21 for a new skin alteration to her left heel, however it did not include interventions specific to relieve pressure to the resident's heels. Skin audits reviewed from 10/28/2020 through 12/30/2020 read that she had areas of redness to her groin and under breasts; however, she did not have skin breakdown or open areas noted. The skin audit dated 1/12/21 documented a skin alteration was found on her left heel by the nursing team and was described as 100% eschar without a size defined. The skin audit dated 1/19/21 documented the right heel had an unstageable pressure ulcer that measured 4.0 cm by 4.0 cm and was 100% eschar. The skin audit dated 1/26/21 documented the right heel had a measurement of 4.5 cm by 4.0 cm of 100% eschar. A general progress note written by the IDON on 1/19/21 at 8:57 a.m. read wound team rounds were completed with the wound doctor and Resident #78's wound on her left heel was diagnosed as unstageable pressure ulcers with 100% eschar. Physician orders [REDACTED]. The care plan revised on 1/12/21 had added interventions related to left heel pressure ulcer were, administer treatments as ordered by the physician, encourage and assist the resident to reposition, pressure reduction surface for her bed and wheelchair, and to monitor the wound for infection. Physician orders [REDACTED]. D. Interviews Registered nurse (RN) #5 was interviewed on 1/19/21 at 10:56 a.m. RN #5 said Resident #78 had a pressure injury on her heel that was black with eschar. She said the wound team followed the pressure injury. RN #7 was interviewed on 1/20/21 at 4:15 p.m. She stated added interventions to the basic care plan for residents admitted with a wound or with a risk for skin breakdown. Residents who were at high skin risk of skin breakdown were repositioned frequently but she did not give a definitive time frame of when the resident should be turned. Unit manager (UM) #1 was interviewed on 1/21/21 at 3:00 p.m. UM #1 said a braden scale assessment was completed weekly and a skin audit was completed daily when a resident had a pressure injury. Resident #78 had a care plan for skin alteration risks; however, it did not include resident specific needs for pressure relief to the left heel. The UM #1 confirmed the unstageable pressure injury to her left heel was identified on 1/12/21. IV. Resident #81 A. Resident status Resident #81, over [AGE] years of age, was admitted on [DATE]. According to the December 2020 computerized physician orders [REDACTED]. The 11/18/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of three out of 15. He required extensive assistance with bed mobility, transferring, dressing, toileting and personal hygiene. It revealed he did not have pressure injuries and had a risk of developing pressure injuries. He also required oxygen by nasal cannula B Observations On 1/19/21 at 11:06 a.m., housekeeping aide (HSKP) #1 told certified nursing aide (CNA) # 15 that Resident # 81 was complaining of pain where his oxygen cannula and eye glasses were resting behind his left ear. HSKP #1 pointed out the area behind the resident's ear to the CNA as she had gloves on that she touched the trash with and then touched the resident's nasal cannula (cross-reference F695, respiratory services). The area had an open sore behind his left ear that drained pink fluid and crusted particles on the hair and skin around the sore. The wound did not smell, and it was about the size of a quarter. On 1/21/21 at 3:00 p.m. the resident's grey foam ear protectors were not on the nasal cannula tubing and were on the resident's bedside table. C. Record review The 12/20/2020 Braden risk assessment tool revealed that the resident was at moderate risk for skin breakdown related to limited mobility and movement. The skin audit on 12/20/2020 revealed the resident had a closed pressure injury area, behind left ear. The skin audit on 1/19/21, revealed the area behind his left ear was open and drained fluid. -The resident did not have a skin audit between the two documented skin audits. The wound team assessment on 12/14/2020 documented the pressure ulcer on his left ear was closed with pinkness and measured 3mm and was a stage 1. The wound team assessment on 1/12/21 read that the resident's pressure ulcer behind his left ear was 3 mm by 4 mm and drained fluid. The stage of the wound was not indicated on the assessment. -The wound assessment team did not have a documented assessment in between these two dates to determine the progression of the wound and the interventions were effective. The care plan was last revised on 1/19/21 identified the resident was at risk for skin breakdown. The care plan was revised to include, follow physician treatment orders, provide foam protectors to nasal cannula tubing, and monitor for evidence of infection. On 1/19/21 at 12:30 p.m. during record review, there were no orders about the resident wound care documented on the wound sheet or in electronic medical administration record. D. Interviews The IDON was interviewed on 1/19/21 at 12:05 p.m. She said the wound team was updated about the pressure ulcer behind the resident's ear, and began monitoring and treating the wound. She said that gloves that were used to touch trash are not to be used to touch oxygen delivery devices or items that touched an open wound. UM #1 was interviewed on 1/19/21 at 4:30 p.m. She said a daily skin audit was required for residents who had a pressure ulcer. The wound team completed assessments weekly with the wound doctor. The UM #1 reviewed the medical record and confirmed the missing skin audit between 12/14/2020 until the next skin assessment performed on 1/19/21. Within that time frame the resident's pressure injury area at the top of his ear crease had worsened from a pink pinpoint area that was closed and turned into a stage 2 pressure injury. V. Resident #70 A. Resident Status Resident #70, age 82, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 12/23/2020 minimum data set (MDS) assessment revealed that the resident had severe cognitive impairment with a brief interview for mental status (BIMS) of 2 out of 15. The resident required two-person extensive assistance for bed mobility, dressing, toileting, and personal hygiene. She required supervision for eating. According to the MDS, transfers only occurred once or twice and required two-person physical assistance. She had a pressure ulcer/injury and was at risk for developing pressure ulcers/injuries. She was always incontinent of bowel and bladder. B. Observations -On 1/18/21 at 1:17 p.m., Resident #70 was observed lying in bed, on her back with her eyes closed. -On 1/19/21 at 9:05 a.m., the resident was observed in bed, positioned on her back with her eyes closed. -On 1/19/21 at 12:47 p.m., the resident was observed sitting up in bed eating lunch. She was positioned on her buttocks as she ate her lunch. -On 1/19/21 at 3:13 p.m., the resident was observed in bed positioned on her back as she watched television. -On 1/19/21 at 3:28 p.m., certified nurse aide (CNA) #16 entered Resident #70's room to provide incontinence care to the resident. The resident was observed to be lying on her back upon entry to the room. CNA #16 rolled the resident and removed her wet brief. Observation of Resident #70's buttocks revealed a quarter-sized open area on each buttock. The CNA placed a new brief on the resident, but did not reposition her off of her back prior to leaving the room. -On 1/20/21 at 9:43 a.m., Resident #70 was observed lying on her back in bed with her eyes closed. -On 1/20/21 at 11:22 a.m., the resident was observed still lying on her back in bed with her eyes closed. C. Record Review The Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documented Resident #70 was at risk for developing pressure ulcers/injuries. Review of the care plan (CP) revealed the resident had a CP initiated on 12/9/2020 for deep tissue injury (DTI) and open sores at buttocks and coccyx related to incontinence and impaired mobility. Pertinent interventions included encouraging and assisting as needed to turn and reposition the resident. Further review of the CP revealed the resident also had a CP initiated on 12/9/2020 for being at risk for alteration in skin integrity related to impaired mobility and incontinence. Pertinent interventions included encouraging the resident to reposition as needed and observing skin condition with ADL (activities of daily living) care daily and reporting abnormalities. Review of the January 2021 CPO revealed the following physician orders: -Apply butt paste (moisture barrier cream) to coccyx/buttocks every shift and PRN (as needed) for redness/excoriation. The date of the order was 12/9/2020. -Body audit daily by licensed nurse, write progress notes, update skin sheets and care plan every evening shift for skin observation. The date of the order was 12/9/2020. -Daily body audits. Please document findings in skin progress notes at bedtime for skin breakdown monitoring. The date of the order was 1/12/21. Review of the nurse progress notes revealed there was no documentation regarding Resident #70's skin issues on the following dates: 12/11, 12/13, 12/16, 12/17, 12/18, 12/21, 12/23, 12/24, 12/25, 12/26, 12/27, 12/28, 12/30, 12/31/2020, 1/1, 1/4, 1/5, 1/6, 1/7, 1/8, 1/9, 1/10, and 1/16/21. Review of the Skin Alteration Record (SAR) sheets for Resident # 70 revealed the left buttock and right buttock wounds were documented on separate sheets and documented the following: -The SAR was not completely filled out for the left buttock on 12/21, 12/29/2020, and 1/3/21. -The SAR for the left buttock had not been completed since 1/3/21. -The SAR was not completely filled out for the right buttock on 12/12/2020. -The SAR for the right buttock was not completed between the dates of 12/29/2020 and 1/16/21. Further review of the SAR for the left buttock wound revealed the following: -On 12/9/2020, the date of the resident's admission to the facility, the wound measured 1.8 centimeters (CM) long, 1.6 CM wide, and 0.1 CM deep. -On 12/10/2020, the wound measured 1.8 centimeters (CM) long, 1.6 CM wide, and 0.1 CM deep. -On 12/12/2020, the wound measured 1.8 centimeters (CM) long, 1.6 CM wide. There was no measurement for the depth of the wound documented on the SAR. -There were no further entries for the left buttock wound measurements documented on the SAR. Further review of the SAR for the right buttock wound revealed the following: -On 12/9/2020, the date of the resident's admission to the facility, the wound measured 1.2 CM long, 1.0 CM wide, and 0.1 CM deep. -On 1/16/21, the wound measured 1.0 CM long, 0.8 CM wide, and 0.0 CM deep. -There were no further entries for the right buttock wound measurements documented on the SAR. D. Interviews Registered nurse (RN) #4 was interviewed on 1/19/21 at 1:23 p.m. RN #4 said residents should be repositioned at least every two hours. The interim director of nursing (IDON), unit manager (UM) #1, and RN #7 were interviewed together on 1/19/21 at 4:28 p.m. UM #1 said every resident received a skin assessment on a weekly basis. She said if the resident had a skin issue it should be documented weekly on the SAR for the resident, which was kept in a binder at each unit nurses station. She said if the resident had a pressure ulcer/injury, the nurses should do a skin assessment daily and document their assessment in a skin note under the progress notes section of the electronic medical record (EMR). RN #7 said if a resident had a skin issue she would expect to see skin notes documented for that resident. She said interventions were put into place on the resident care plan, and staff should follow those interventions. She said CNAs should do frequent repositioning of residents with skin issues and those who were at risk for developing skin issues. She said the facility did not have a set protocol for how often a resident should be repositioned, but she said she would expect staff to reposition high risk residents at least every two to three hours. CNA #16 was interviewed on 1/19/21 at 5:46 p.m. CNA #16 said residents should be repositioned every two hours. VI. Resident #15 A. Resident status Resident #15, age 84, was admitted on [DATE]. According to the January 2021 computerized providers orders (CPO), [DIAGNOSES REDACTED]. According to the 1/7/21 minimum data set (MDS) assessment, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had no behavioral symptoms or rejection of cares. The resident required extensive assistance of two persons for bed mobility, dressing, toilet use and personal hygiene. The MDS assessment revealed the resident was incontinent of bladder and bowel, did not have pressure ulcers/injuries but was at risk for developing pressure ulcers/injuries. The assessment lacked the resident's weight. According to the 10/9/2020 MDS assessment, the resident weighed 172 pounds. B. Observation and interview On 1/13/21 At 12:20 p.m. the resident was in bed with the head of the bed slightly elevated. The resident pointed at a white board with times written on it, 11:30 a.m., 4:30 p.m., 9:00 p.m., 2:00 a.m. She said those were the times staff were to provide incontinence care. The resident said they were not following the incontinence care schedule, that she had to remind them, and she was concerned she was getting a pressure ulcer on her right buttock. The resident said a nurse told her they did not follow schedules in the isolation unit. The resident said she used to be able to sit in her electric wheelchair, but was not allowed to have it while in isolation on the COVID-19 unit. On 1/18/21 At 2:11 p.m., the resident was lying on her left side with the head of the bed slightly elevated. The certified nurse aides (CNAs) provided a change of position to have the resident on her back and the head of the bed more elevated. The incontinence change schedule of 11:30 a.m., 4:30 p.m., 9:00 p.m., 2:00 a.m. was no longer written on the white board and the resident said someone erased it over the weekend. On 1/19/21 Between 10:00 a.m. and 12:23 p.m., the resident was lying on her back with the head of the bed in a very high position. No position changes were offered or provided during that time period. At 11:43 a.m., licensed practical nurse (LPN) #3 administered medications to the resident. No position change was offered by the LPN. At 12:23 p.m., a CNA delivered the midday meal. No position change was offered by the CNA. On 1/20/21 At 9:48 a.m., the resident was lying in bed, on her back, with the head of the bed slightly elevated. The resident remained in the same position until 12:58 p.m. The resident said staff had provided incontinence care as scheduled that morning. At 12:47 p.m., the resident activated the call light. At 12:49 p.m. the resident called out, I could use some help and repeated several times, Answer my call light please. At 12:50 p.m., LPN #3 entered and told the resident the aides were with someone else and would be with her shortly. At 12:58 p.m., CNA #1 and CNA #11 entered the resident's room and provided incontinence care. LPN #3 entered the room while the CNAs provided incontinence care. The resident told them she was worried she was getting a pressure ulcer on her bottom and told the aides several times that it hurt when the CNA wiped the area. LPN #3 applied the prescribed ointment after the aides completed the incontinence care. Observation of the resident's right buttock at that time revealed non-intact skin of approximately 1.5 cm x 0.5 cm with the surrounding intact tissue brownish in color of approximately 4 cm x 5 cm. LPN #3 was interviewed immediately prior to the application of the ointment. The LPN was asked if the resident had a pressure ulcer, she stated the wound was chronic maceration (inflammation or skin erosion). The LPN said wound measurements and staging were not done by her but were done on Tuesdays by the wound care team. Before leaving the resident's room, LPN #3 asked the resident if she would change her position off her back to her left side. The resident agreed and CNAs positioned the resident to her extreme left side with a pillow supporting the resident's back. At 1:11 p.m. the resident activated her call light and immediately started calling out, I need help. LPN #3 entered the resident's room and the resident told her she needed to get off her left side. At 1:17 p.m., Resident #15 was interviewed. The resident stated her left leg had gone numb from lying on it. Resident #15 said they had not offered slight position changes and to lay completely onto her left hip was painful. C. Record review The Braden Scale for Predicting Pressure Sore Risk dated 1/8/21 assessed the resident at moderate risk of 13 out of 18. The activities of daily living care plan, initiated 2/7/18 and revised 6/4/2020, read in part, the resident will notify staff when she wants to be changed. Interventions included allowing flexibility and if the resident resists care, leave and return later. Staff were to provide education about the risks of not complying with the therapeutic regimen. The skin integrity care plan, initiated 11/21/17 and revised 2/17/2020 read in part that a pressure redistributing device was placed on her bed and chair. The gastrointestinal care plan, initiated 12/4/17 without revision directed staff to elevate the head of the bed as needed related to gastroparesis (delayed emptying of the stomach). A progress note dated 11/25/2020 at 8:05 a.m. read in part that the wound team members assessed skin alterations to the resident right buttock. It further read that the resident had an incontinence care schedule of 2:00 a.m., 11:30 a.m., 4:30 p.m. and 9:30 p.m. The resident's skin integrity care plan failed to include the incontinence care schedule. A general progress note dated 12/26/2020 at 6:59 p.m. for a body audit that read in part, that the skin issue to the resident's buttock was resolved. Further review of the resident's record failed to reveal any body audit progress notes after 12/26/2020. A social services progress note dated 1/18/2021 at 5:59 p.m. The note read in pertinent part, When asked if the resident had concerns with her care, the resident stated yes, that she is not getting what she needs. She stated that she isn't on a schedule for changing like she was when she was in her old room. The unit manager will be informed of this concern. The resident's record lacked documentation of the 1/20/21 at 12:58 p.m. observation of a pressure ulcer of approximately 1.5 cm x 0.5 cm observed during incontinence care lacked documentation of any skin concerns until 1/21/21 at 8:53 a.m. A progress note dated 1/21/21 at 8:53 a.m. revealed a skin alteration measuring 1.5 cm x 0.7 cm with surrounding tissue to be dark in color. Skin Alteration Record sheets were provided by the interim director of nursing (IDON) on 1/21/21 at 9:00 a.m. The Skin Alteration Record sheet dated 1/21/21 recorded measurements of 1.5 cm x 0.7 cm but lacked documentation of the type of alteration of concern. Refer to unit manager (UM) #1 staff interview of 1/21/21 at 12:39 p.m. The residents medical record lacked Skin Alteration Record sheets between 11/14/19 and 1/21/21. D. Staff interviews UM #1 was interviewed on 1/19/2021 at 4:29 p.m. UM #1 said all skin audits were charted in the electronic medical record. She said floor nurses performed head to toe body audits weekly and charted concerns in a progress note. She said pressure ulcer/injuries were documented daily in progress notes. The UM said wound tracking was also documented on Skin Alteration Record forms that were kept in binders at the nurses station. UM #1 said a weekly wound care team, to include a physician, assessed, measured, diagnosed and prescribed treatments. She said if a resident is considered high risk for pressure sores using a Braden Risk assessment, interventions such as an air mattress, skin treatments, and frequent repositioning are done. CNA #11 was interviewed on 1/20/21 at 1:55 p.m. The CNA stated the resident had urinary incontinence, did not have an incontinence care schedule and at times preferred to not change her position. CNA #11 stated position changes were not offered if the resident prefered not to have incontinence care. LPN #3 was interviewed on 1/21/21 at 3:30 p.m. The LPN said she considered the resident's skin alterations as chronic maceration. UM #1 was again interviewed on 1/21/21 at 12:39 p.m. The UM stated she assessed Resident #15's wound that morning and documented in the progress notes and on the Skin Alteration Record dated 1/21/21. She confirmed the wound was now a non-intact skin alteration. UM #1 said the wound care team will stage the wound.

Based on observation, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans for four (#49, #17, #55 and #83) of four out of 58 total residents. Record review and interviews revealed the facility failed to follow-up with a dental specialist on the resident's complaints of jaw pain. The resident had been complaining of jaw pain since 11/11/2020. Although the resident was seen by her primary care physician she had not been seen by a dental specialist and had no diagnostic tests to determine the cause of her jaw pain. According to a care plan note dated 11/27/2020, direct care staff were reporting that Resident #49 was indicating jaw pain and rubbed her jaw daily. On 12/29/2020 the resident presented with redness and swelling to the left side of her lip and her left lower gums were red with an elevated white/yellow boil at the gum level. The resident complained of increased pain to the left side of her face. Following an exam by the resident's physician she was diagnosed with [REDACTED]. The physician placed an order on 12/29/2020 for the resident to see a dentist. As of 1/21/21, the facility still had not secured a dental appointment for the resident. The facility said the dentist they used would not come to the building because of the COVID-19 pandemic; they had not considered sending her to a different community dentist. The facility failed to provide Resident #49 proper dental care and assessment.The facility's failures contributed to the resident suffering prolonged jaw pain, swelling, and oral infection that required treatment with antibiotics and a narcotic [MEDICATION NAME]. In additon, the facility failed to ensure: -Resident #17 was seen by a podiatrist as ordered by the physician; -Resident #55's physician orders [REDACTED]. -Resident #83's physician orders [REDACTED]. Findings include: I. Resident #49 A. Facility policy and procedure The Dental Services policy and procedure was requested on 1/21/21 at 9:14 a.m. The interim director of nursing (IDON) said the facility did not have a specific policy for dental services. On 1/21/21 at 12:40 p.m. the IDON provided a document titled Services dated 2016. It read in pertinent part: An aspect of advocacy involves linking and coordinating services that may or may not be available within the facility, or are beyond the scope of the facilities role. These services may include, but are not limited to: .dental, vision, auditory and podiatry services . -Referrals are made with permission or input from the patient or patient representative, and involvement of the attending physician, when appropriate. Patient choice guides the selection of services. -It is advisable for the social service employee to adequately note referral activities including: the purpose of the referral, the provider contacted, and the patient's opinion of the service especially if the patient is displeased. B. Resident status Resident #49, under the age of 65, was admitted on [DATE]. According to the January 2021 computerized physician orders [REDACTED]. The 11/27/20 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a brief interview for mental status score of zero out of 15 because the resident could or would not answer assessment questions. Assessment revealed the resident was experiencing an acute change in mental status from the baseline; with inattention and difficulty focusing attention, having difficulty keeping track of what was being said, and disorganized thinking. The resident displayed physical and verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others. These behaviors significantly interfered with the resident's care. The resident was not able to answer questions about experienced pain. Staff assessment documented the resident was experiencing daily pain as evidenced by protective body movements or postures such as bracing, guarding, rubbing or massaging a body part/area, clutching or holding a body part during movement. There was no documentation of dental concerns. C. Record review A medical practitioner (physician/nurse practitioner-NP) medical necessity note dated 11/11/2020 at 3:37 p.m. revealed in part: the resident was seen for headaches and facial pain. Chief complaint: the resident has been complaining of headaches and left sided facial pain. The resident has [MEDICAL CONDITION], and it was so hard to understand her description. Sounds like sinus congestion or pain from her description. She is struggling with agitation and anxiety today, she became aggressive and upset on a couple occasions, wanted to leave and go home. History of present illness: the resident's other headache syndrome is reportedly stable. She has a headache today, no focal signs or symptoms of stroke or any issue other than tension headache. She doesn't have any pain medications. Resident was reportedly stable with respect to nasal congestion. I suspect she could benefit from [MEDICATION NAME], etc., but I do not think she would cooperate with a nasal inhaler. She will take pills. Assessment and Plan: -Other headache syndrome: Tylenol 650 milligrams (mg) every six hours as needed; -Nasal congestion: [MEDICATION NAME] 600 mg tab twice a day as a trial, to see if it helps. A medical practitioner (physician/NP) medical necessity note dated 11/13/2020 at 6:02 p.m. revealed in part: the resident was seen on a follow up visit agitation and aggression. Chief complaint: Resident had been getting very agitated and aggressive at times. Gets very anxious. History of Present Illness: Resident is on [MEDICATION NAME] (anti-anxiety medication) order as needed. Staff wondering if scheduling the [MEDICATION NAME] it may be of benefit. Resident gets agitated easily, especially when she has difficulty making her needs known. She can be difficult to redirect. Past Medical History: Other specified anxiety disorders. Jaw pain. Other headache syndrome. Nasal congestion. Assessment and Plan: Other specified anxiety disorders: Will give [MEDICATION NAME] 0.5 mg twice a day to, see if this helps .[DIAGNOSES REDACTED]. A medication administration note dated 11/14/2020 at 2:15 p.m., revealed the resident was given 650 MG of Tylenol as requested for pain around the right side of her face. The resident assessed her pain level to be a 3 out of 10. A medication administration note dated 11/16/2020 at 2:46 a.m., revealed the resident requested something for pain on her left side. The resident was unable to articulate what was wrong, no noted injury to her person. The resident was offered Tylenol. She initially refused then accepted the Tylenol. A medical practitioner (physician/NP) medical necessity note dated 11/16/2020 at 9:30 a.m. revealed in part the resident was seen for a Medical necessity of visit: complaints of jaw pain. Chief complaint: patient is complaining of jaw pain. She did not sustain any injury that she knows of. Also, seen for follow up on her anxiety. History of Present Illness: Resident #49 was seen for Jaw pain. No injury noted. She denies trauma. No dental problem that I see. She has Tylenol for pain, just got a dose. The patient's other specified anxiety disorder was evaluated today. She has [MEDICATION NAME] twice daily and has prn order as well. Past medical history: .jaw pain. A care plan progress note dated 11/27/2020 at 2:00 p.m. read in part: Resident interview for significant change of status .The resident does not wear dentures and denies oral or dental pain with eating and drinking. She could not answer if she has had pain in the last five days. Direct care staff said Resident #49 rubs her jaw daily. She has as needed an order for [REDACTED]. Assessment and Plan: -Jaw pain: Will see how she does with Tylenol, see if this resolves. I don't see a cause at this time. A general nursing progress note dated documented, Tylenol administered. Physician assessed resident, new orders received for in house dentist appointment, [MEDICATION NAME] antibiotics prescribed for 10 days and as needed [MEDICATION NAME]. Warm salt-water mouth rinse administered. First antibiotic dose administered without any adverse reactions. A medical practitioner (physician/NP) medical necessity note dated 12/29/2020 at 6:30 p.m. revealed in part: the resident was seen for mouth pain. History of present illness: nursing reports resident was having mouth pain. Assessment and Plan: -Other specified disorders of teeth and supporting structures: mild swelling to lower lip, one (1) CM white pustule (boil) in gum line, pain and some redness to lower left gums, will start antibiotic treatment for 10 days with [MEDICATION NAME], will offer [MEDICATION NAME] as needed for three days as the resident was still in pain after Tylenol. A physician's/prescriber sheet documented a physician order [REDACTED]. A social services note dated 1/12/21 at 2:41 p.m. revealed the nurse informed this writer that the resident needs to see a dentist. Email requested for a dentist visit. Awaiting call back from the provider. There was no other social service documentation to show attempts to seek a dental referral or dental appointment for the resident. The care plan initiated 10/27/2020 revealed the resident had a care focus for pain related to disease process and stroke with a goal that the resident will express that pain management was within acceptable limits. Interventions included: administer pain medication per physician orders; implement non-pharmacological interventions music, art, drama therapy, exercise, therapeutic modalities (e-stim, TENS, cryotherapy, thermal therapy, biofeedback), acupuncture, acupressure, massage, ultrasound, relaxation techniques, counseling, warm/cool compress, positioning, to assist with pain and monitor for effectiveness; provide education to family/patient. There was no mention of the resident's jaw pain or methods of oral care management. D. Staff interviews Registered nurse (RN) #8 was interviewed on 1/19/21 at 3:50 p.m. RN #8 said Resident #49 was very restless and would snap at staff quickly. Staff needed to take a calm approach with her and let her wander a bit and redirect her back to her room. It was hard to tell if the resident was in pain because she was not a good self-reporter, and often could not find the words to express how she was feeling. Resident #49 would get frustrated with staff if they asked her for too many details and she was having trouble explaining herself. She did remember the resident complaining of jaw pain and getting Tylenol to relieve the pain until the oral infection when the resident's pain increased and she was more agitated Unit manager (UM) #1 was interviewed on 1/20/21 at 2:25 p.m. The UM said she remembered the resident was admitted with jaw pain and they had the resident's physician examine her. At the time he could not find any cause for the pain because her complaints were intermittent. The dental provider they used was not scheduling appointments during the COVID-19 pandemic unless it was an urgent need, and the interdisciplinary team (IDT) felt the resident's pain was managed and she could wait to see the dentist. The social work coordinator (SWC) was interviewed on 1/21/21 at 10:15 a.m. The SWC said the social work department was responsible for making referrals for dental services and arranging dental appointments for the residents at the facility. The SWC said due to the COVID-19 pandemic the mobile dental provider would not come to the facility, so they had to wait until the provider would agree to make an in-house visit. She had not considered another vendor or making arrangements for the resident to go to a dental provider office for dental services. She said she would follow-up on the status of Resident #49's dental appointment. II. Resident #17 was seen by a podiatrist as ordered by the physician A. Resident status Resident #17, age 80, was admitted on [DATE]. According to the January 2021 computerized physician orders, [DIAGNOSES REDACTED]. The 10/20/2020 minimum data set (MDS) assessment showed the resident had no cognitive impairment with a brief interview for mental status score of 15 out of 15. The resident required extensive assistance with personal hygiene. B. Record review The physician telephone order dated 11/3/2020 documented an order for [REDACTED]. The 11/3/2020 medical practitioner note documented, the resident had complained of pain between the 4th and 5th toes on her right foot. The note documented, between 4th and 5th toe of her right foot there was a hole in the skin between the webbing, and it did not appear infected. The size of the hole was approx 2-3 mm in diameter and 1.5 mm deep. No discharge or [DIAGNOSES REDACTED], painful to manipulation. The medical record failed to show evidence that the resident was seen by the podiatrist or wound physician for the area mentioned above. C. Resident interview Resident #17 was interviewed on 1/18/21 at approximately 2:00 p.m. The resident said that she had not seen a podiatrist for quite some time. She said she would like to see one because she needed her feet to be looked at. She said that at night her right foot between her 4th and 5th toe hurts. D. Observation On 1/20/21 at 11:00 a.m., the resident's right foot was observed. The licensed practical nurse (LPN) #1 was observed to separate the 4th and 5th toe. Between the toe was dry skin, and the healed hole could be observed. E. Interview The interim director of nurses (IDON) and unit manager #1 were interviewed on 1/19/21 at approximately 4:00 p.m. The IDON reviewed the record and could not find any evidence that the resident was seen by a podiatrist. The UM #1 said since the pandemic, the podiatrist had not been into the building. The IDON said the wound physician had not seen the resident either. The IDON said the expectation was to ensure the physician orders [REDACTED].>III. Resident #55 physician orders [REDACTED]. A. Resident status Resident #55, age 80 , was admitted on [DATE]. According to the January 2021 CPO [DIAGNOSES REDACTED]. The 12/4/2020 minimum data set (MDS) assessment showed the resident had moderately impaired cognitive impairment with a brief interview for mental status score of nine out of 15. The resident required extensive assistance with activities of daily living. The resident was coded as receiving opioids seven days a week. The resident experienced pain frequently. B. Record review The January 2021 CPO ordered for the resident's pain level to be monitored every shift using a pain scale of 0-10, and to document on the Medication Administration Record [REDACTED] The January 2021 CPO -[MEDICATION NAME] HCL 10 mg by mouth every six hours as needed for pain greater than six on the numeric pain scale. Numeric pain scale with a start date of 9/16/2020. -[MEDICATION NAME] HCL 5 mg mg by mouth every six hours as needed for pain less than five on the numeric pain scale. Numeric pain scale with a start date of 9/16/2020. The December 2020 Medication Administration Record [REDACTED]. -12/3/2020 pain level was 4/10 at 9:31 a.m., and pain level of 4/10 at 6:02 p.m.; -12/4/2020 pain level was 4/10 at 8:57 a.m., and pain level of 5/10 at 10:05 p.m. ; -12/5/2020 pain level was 5/10; -12/7/2020 pain level was 5/10; -12/10/2020 pain level was 5/10; -12/13/2020 pain level was 5/10; -12/14/2020 pain level was 4/10 and at 4:07 p.m.; -12/17/2020 pain level was 5/10; -12/18/2020 pain level was 4/10 at 9:02 and pain level was 5/10 at 4:17 p.m. and pain level of 4/10 at 10:23 p.m.; -12/21/2020 pain level was at 8:43 a.m., and pain level at 5/10 at 6:27 p.m.; 1/15/21 pain level at 3/10 1/16/21 pain level at 5/10 at 7:30 a.m., and a pain level of 5/10 at 5:56 p.m. C. Interview The registered nurse (RN #3) was interviewed on 1/21/21 at approximately 11:00 a.m. The RN reviewed the physician order [REDACTED]. She said the resident requested two tables for a total of 10 mg often, as she wanted it to help her sleep. The RN said the physician should be contacted in regards to the physician order [REDACTED]. IV. Resident #83 A. Professional reference According to Clinical Nursing Skills & Techniques, by Perry, Potter & Osterdorf, 8th Edition (copyright 2014), page 480-489: Safe Medication Administration: To prevent medication errors, follow the six right of medication administration consistently every time you administer medications. Many medication errors are linked in some way to the inconsistency in adhering to the six rights: 1. The right medication 2. The right dose 3 The patient 4. The right route 5. The right time 6. The right documentation -Read the label on the medication container and compare it with the MAR (medication administration record) at least 3 times: before removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering. B. Resident status Resident #83, age 75, was admitted [DATE] and readmitted on [DATE]. According to the 1/14/21 computerized physician orders [REDACTED]. According to the most recent minimum data sect ((MDS) dated [DATE] the resident had a brief interview for mental status of 15 out of 15 which indicated cognitively intact. The resident required partial to moderate assistance bathing, taking on and off footwear, and dressing below the waist. C. Record review The care plan initiated on 10/11/2020 documented to administer medications according to physician orders. The Medication Administration Record [REDACTED] -Give 12.5mg (milligram) of [MEDICATION NAME] (used to treat high blood pressure) by mouth twice daily for heart rate stabilization. Hold for blood pressure less than 100(systolic)/50 (diastolic). The blood pressure was to be taken prior to administering the medication. The blood pressure parameters were reviewed January 2021 for the medication [MEDICATION NAME]. The following documentation revealed the medication was still given when the diastolic number was below the given parameter of 50: -On 1/2/21 blood pressure was 126/49; -On 1/8/21 blood pressure was 115/48; -On 1/9/21 blood pressure was 124/42; -On 1/10/21 blood pressure was 107/45; -On 1/11/21 blood pressure was 129/49; -On 1/12/21 blood pressure was 132/47; -On 1/14/21 blood pressure was 108/46; and, -On 1/20/21 blood pressure was 127/47. IV. Interview The unit manager (UM) #1 was interviewed on 1/20/21 at 3:15 p.m. She said parameters for administering medications are to be followed by the staff. She said if we do not follow the physician orders [REDACTED]. She said if the parameter to give the medication was for the blood pressure not to be below 100/50, she would not have given the medication and then she would have called the provider immediately. She said the resident could have had severe problems and the staff should not have given the medication with the parameters not met.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, for one of two residents (#96) reviewed for pain management out of 58 sample residents. Resident #96 had a history of [REDACTED]. While in the care of the facility, Resident #96 had an unwitnessed fall with a major injury on 10/8/2020 at 12:00 p.m. immediately following the fall a nurse assessed the resident for injuries and observe the resident to complain of right wrist and hip pain with a decreased ability in range of motion and a visible shortening of the resident's right leg. The resident's pain level was not assessed. The resident's physician was notified and x-rays of the resident's extremities was ordered. Pain medication was administered 10 and a half hours after she first complained of pain. The available pain medication was assessed to be ineffective and the resident remained in pain for over 19 hours while she waited in the facility for diagnostic tests to confirm her fractures and for an ambulance to be called to transport her to the hospital emergency room for medical intervention and surgical treatment of [REDACTED]. The facility's failures contributed to the resident suffering prolonged pain from hip and wrist fractures. Cross-referenced to F689 failure to prevent a resident fall with a major injury and F580 failure to notify the physician when pain management was ineffective. Findings include: I. Facility policy and procedures The facility's pain management policy was requested on 1/21/21 at 9:14 a.m., to the interim director of nursing (IDON). A practice guide was provided. The Pain Practice Guide, dated November 2011, was provided by the nursing home administrator (NHA) on 1/29/21 at 12:25 p.m. It read in part: The information included within this guide does not relieve a business unit/facility of the obligation to comply with all applicable corporate policies as well as federal and state regulations. - The purpose of the Pain Practice Guide is to describe the process steps for techniques and interventions to prevent and, or manage pain both chronic and acute. - The progression of pain is often described as a vicious cycle. Pain occurs when a noxious stimulus - mechanical, chemical, or thermal -results in actual tissue damage. The physiologic response triggers to this perception include guarding, splinting and muscle tension, which generate additional chemical factors with further physical, physiologic and psychological ramifications. -Pain that is not treated effectively at any point in the cycle can lead to chronic pain. -If a patient has evidence of pain or a condition with recurring episodes of pain, the physician is notified to obtain orders for pain medication. The NHA was interviewed on 2/1/21 at 8:36 a.m. The NHA said the facility used the Pain Practice Guide as their policy for pain management; all staff have access to the practice guide and are trained to the practice guide. II. Resident #96 A. Resident status Resident #96, over the age 85, admitted on [DATE]. The resident passed away and was discharged from the facility on 11/6/2020. According to the November 2020 computerized physician's orders [REDACTED]. Repeated falls was listed as an admission diagnosis. The 9/4/2020 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. The resident was not receiving regularly scheduled pain medication and could not say if she had experienced pain in the last five days. B. Record review The comprehensive care plan revised 9/14/2020 revealed the resident had chronic pain. Interventions included: report nonverbal expressions of pain such as moaning, striking out, grimacing, crying, thrashing, change in breathing, etc. and administer pain medication per physician orders. The October 2019 CPO revealed the following orders related to pain management: - Tylenol tablet ([MEDICATION NAME]), give 650 milligrams (MG), by mouth, every four hours, as needed for pain. Start date 6/24/19. Progress notes revealed: -A general nursing note dated 10/8/20 at 1:11 p.m., read: At 12:00 p.m., a CNA entered the resident's room and found her sitting on the floor in front of the bathroom complaining that her hand hurt. A registered nurse assessed and noted the resident's right leg appears shorter than the left leg. Resident complained of pain to the right hip as well as the right hand and wrist. Resident had decreased range of motion (ROM) to the right upper and lower extremities. The unit manager reported the incident to the resident's physician and got orders for x-rays. The resident's actual pain level was not documented. -A general nursing note dated 10/8/2020 at 6:55 p.m., read: Resident on monitoring for fall follow up .Resident states her right wrist hurts, and she does not know what happened. Resident does not remember that she fell earlier. X-ray pending. There was no documented assessment of the resident pain level. -A general nursing note dated 10/8/2020 at 7:00 p.m., read: Call placed to the mobile x-ray provider, by this nurse to follow up on order for x-ray. This nurse was told that their system was down and they were just now putting in orders that were received during that time. X-Ray to come shortly. -A medication administration note dated 10/8/2020 at 10:30 p.m., revealed the resident received Tylenol tablets, 650 milligrams (mg) for Pain. -A general nursing note dated 10/9/2020 at 3:44 a.m., read: Resident on fall follow .Resident not able to move right leg with pain. Resident did not want to stay in her room stating that she was scared; she was brought to the nurse's station at 10:30 p.m. in a wheelchair to be monitored closely. At approximately 12:30 a.m., the resident was tired and requested to sleep. Resident placed in bed. Resident stated she felt better laying down, she soon fell asleep. Resident was not able to bear weight on her right leg. Tylenol given at 10:30 a.m., it was not effective in easing pain. Resident repeatedly complained of pain in her leg and all over her body. Despite the resident having been assessed to have hip pain following an assessed deformity documented as a shortening of her right leg facility staff got her up into a seated position in a wheelchair to sit for a period of two hours before being put back into bed. -A medication administration note dated 10/9/2020 at 12:37 a.m. revealed the resident was assessed for pain following the 10:30 p.m. administration of Tylenol. The note read in part: PRN (as needed) administration of Tylenol 659 MG was ineffective. Follow-up pain scale was 6 out of 10. This was the first documented administration of pain medication; 10 and a half hours after the resident first complained of pain following a fall where she sustained multiple fractures. There was no documentation of pain prior to administration of the PRN Tylenol and the effectiveness of the pain medication was not assessed for an additional two hours after administration. -A general nursing note dated 10/9/2020 at 4:00 a.m., revealed: X-ray results reported acute Distal (outer wrist) radial fracture, with mild soft tissue swelling, and a [MEDICAL CONDITION] femoral neck with superior displacement of the distal fragment. With mild soft tissue swelling. Physician notified. -A general nursing note dated 10/9/2020 at 6:15 a.m., read: .Call placed to the physician. New order received to send out to hospital emergency for evaluation and treatment. Resident was sitting in a wheelchair with the floor nurse to ensure that she did not attempt to ambulate. Complaining of pain, medicated with PRN (as needed) Tylenol with minimal effect. Medical transport picked up residents at 7:00 a.m. In the 19 hours following a fall with pain and injury the resident waited for treatment of [REDACTED]. The one time pain medication administration was ineffective. There was no documentation that the nurse contacted the physician for a stronger pain medication; and the resident's pain level was only assessed one time 12 and a half hours after the fall; two hours after the prn administration of Tylenol. There was no other documentation of pain management treatment. -Hospital health and physical note dated 10/9/2020 R 8:36 a.m., read in part: Assessment: closed fracture of neck of right femur, right distal radius and right wrist. Plan: admit to trauma for pain control. C. Staff interviews Unit manager (UM) #1 was interviewed on 1/21/21 at 2:41 p.m. UM #1 looked at the resident's record for pain management and medication administration and said she did not know why the nurse waited so long to give the resident another dose of Tylenol when the resident was complaining of pain. She said she was surprised to see that the nurse had not administered pain medication (Tylenol) until 10:30 p.m., per documentation on the resident's medication administration record. The UM said staff should go out of the way to make a resident in pain comfortable. She did not know why the nurse did not contact the resident's physician to consult on a resident's unresolved pain. The IDON was interviewed on 1/29/21 at 12:30 p.m. The IDON said if she was the nurse on duty she would have notified the physician of the resident's unresolved pain to see if the doctor would give additional treatment orders for post fall treatment. The medical director (MD) was interviewed on 2/1/21 at 9:30 a.m. The MD my expectation would have been the facility would have contacted the resident's physician to report a change of condition and if after 15 to 30 minutes the physician did not respond the facility should contact the medical director for consultation and orders to address the resident's condition. The medical director is required to be on call for the facility 24 hours a day.

Based on observation, record review and interviews, the facility failed to provide the necessary treatment and services to promote pressure injury healing, prevent pressure injuries from worsening, and maintain accurate skin assessment for two (#61 and #105) of five residents reviewed for pressure injury out of the 37 sample residents. Specifically, the facility failed to: -Timely communicate with primary care physician regarding Resident #61 ' s injury from her leg brace and take immediate action to minimize the injury and prevent worsening at the site. -Complete comprehensive and consistent skin assessments, and continuously tracked the pressure injuries for Resident #105, who was at high risk for pressure injuries. The facility's failures above contributed to the development of two trauma related pressure injuries to Resident #61's left leg. Initial trauma to the left leg started as an abrasion from the pressure of a hinged brace that the resident was wearing and over a month progressed to stage 3 pressure ulcers. Findings include: I. Facility standards Skin practice guide, dated 1/13 with no revised date, was provided by the nursing home administrator (NHA) on 3/26/19 at 12:07 p.m. It read in part , Daily skin evaluations are completed by the licensed nurse for any patient with a pressure ulcer. Weekly skin evaluations are completed by the licensed nurse for any other patient. Skin evaluations are documented in the clinical record. II. Professional reference The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and treatment of [REDACTED]. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, periwound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of [REDACTED]. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014. From http://www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf (11/6/18). III. Resident failures A. Resident #61 1. Resident status Resident #61, age 81, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 1/29/19 minimum data set (MDS) assessment revealed, the resident had no memory problems, with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required extensive assistance of two or more people with most activities of daily living. She was frequently incontinent of bladder, and always incontinent of bowel. During transfers and walking she was not steady, and was able to stabilize with human assistance only. Walker and wheelchair were listed as mobility devices that resident used. The resident was admitted with no existing pressure ulcers, skin tears or other skin issues. 2.Wound care observations and registered nurse (RN )#4 interview On 3/25/19 at 1:46 p.m. Resident #61 was in bed during wound care by RN #4. The resident was positioned on her back with the head of the bed elevated to 35 degrees. The resident was lying on the air mattress with both heels elevated on a pillow. RN #4 removed the dressing dated 3/24/19 from the residents left lower extremity around the knee area. Two wounds in close proximity to each other were revealed. Both wounds had red regular edges with 50 to 60 percent of slough obscuring most of the wound bed. The wounds were measured by the nurse. The large wound measured 3cm x 2cm (3 centimeters by 2 centimeters) and small wound 1cm x1cm. Resident jerked her leg during the treatment, she said it hurt but did not rate the pain on a scale from 0 to 10. RN #4 stated resident acquired both wounds from the hinge brace that she was wearing before. She opened resident closet and demonstrated the brace. She said the resident no longer was wearing this brace as she was bedridden. She said since her admission the resident barely walked at all. Observations of right heel revealed black round area on the back of the heel measuring 1.5cm x 1.5cm. The resident was not able to answer questions about her wounds. 3. Record review -development of pressure injury. a. Care plan The care plan, initiated 1/22/19 and revised 3/20/19, identified the resident had self care deficit related to left knee fixation and impaired mobility. Interventions included to assist with daily hygiene, grooming, dressing, and oral care. The care plan, initiated 1/22/19 and revised 3/20/19, identified the resident was at risk for alteration in skin integrity related to impaired mobility, anticoagulation therapy, poor nutrition, incontinence, and terminal prognosis. Interventions included to apply barrier cream as needed, elevate heels as able, encourage to reposition as needed, observe skin conditions and report abnormalities. The care plan, initiated 2/25/19 (last day of the survey, 3/26/19), identified the resident had an unstageable pressure ulcer on lateral knee and right heel. Interventions included to administer treatment per physician order, elevate heels as able, pressure reducing surface on bed, wound team to follow. The care plan, initiated on 3/11/19 and revised on 3/20/19, identified the resident had skin tear to the right elbow. Interventions included to provide treatment and monitor for infection. There were no care plan for the use of hinge brace. b. Skin assessments Skin alteration record revealed that resident developed redness and two abrasions on her left lateral leg as early as 2/13/19. On 2/15/19 the abrasions increased in size to 2 cm, and had thin red liquid draining from it. On 2/26/19 the open areas had moist yellow necrotic tissue with purulent drainage and the resident had pain at the site. On 3/11/19 (13 days later) resident had an open area of 1cm by 1cm with slough (necrotic tissue), purulent white to yellow discharge and pain at the side. c. Physician orders On admission, 1/22/19 physician order [REDACTED]. On 1/23/19 order to remove brace at left knee every shift and check skin for breakdown was entered. This order was consistently signed by nurses on treatment administration order (TAR). On 2/13/19 order to monitor abrasion on left knee and make sure dressing was intact and in place. On 3/7/19 order was changed to may remove brace from left lower leg. On 3/12/19 order to clean knee abrasion with normal saline, applying skin prep and cover with foam dressing. There were no orders in place to pad the brace. The orders revealed the resident did not have an order for [REDACTED]. d. Wound care notes The notes revealed the resident was followed by the wound care team at the time of the development of the left leg wounds. However, her wounds on the left leg were not assessed by a wound team until 3/12/19 (a month after she developed skin alteration and breakdown under the brace). The resident was followed by the wound team since 2/12/19, at that time she had two wounds on her buttocks that were resolved on 2/26/19, this indicated the residents body had the capability of healing with proper interventions and monitoring. -Thesame note revealed that resident developed a new deep tissue injury (DTI) with a blister to a right heel. Treatment included to apply [MEDICATION NAME] to area twice a day. On 3/12/19 the wound care physician documented the resident has full thickness trauma wound to left lateral leg which measured 4cm x 5cm. Muscle is exposed. There is a small amount of purulent drainage noted. Wound has 40 percent of slough. As a part of the treatment wound physician performed surgical debridement, muscle and subcutaneous tissue were removed along with slough (devitalized tissue). Treatment included to cleanse the wound with normal saline, apply oil [MEDICATION NAME], cover with a pad and wrap with a gauze. Dressing to be changed daily. On 3/26/19 the wound care physician documented the resident had two wounds on her left lateral leg. Both were described as unstageable pressure injuries with obscured full thickness skin and tissue loss. One wound was measuring 1cm x 1.1cm and second on measured 1.8cm x 2.2cm. Both wounds had exposed muscle, and 50 to 80 percent of slought was present in the wound bed. e. Interdisciplinary notes Revealed the resident was mostly beddridden from admission between 1/22/19 and 3/6/19. The notes also revealed the following information: Physicians, nurses and physical therapy progress notes revealed the resident did not ambulate, was not able to self transfer or initiate ambulation. She still was wearing a brace even though she did not ambulate. The order to remove the brace was put in place until 3/7/19 (see physician orders [REDACTED]. Physical therapy notes dated 1/23/19, documented resident was very limited with all activities and mobility due to pain. (She was ) unable to move in bed without maximum assistance. She was unable to stand and walk. Resident was discharged from the therapy on 3/6/19 as she was not able to progress to continue therapy services. On 1/31/19 the physician progress notes [REDACTED]. Note by unit manager/registered nurse (RN) #2, dated 3/28/19, revealed when reviewing documentation it was determined that the Braden completed on 3/15/19 was inaccurate. (Resident) was not working with therapy so was not ambulating even a few steps. The resident did not initiate repositioning or movement. B.Resident #105 1.Resident status Resident #105, age 81, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 11/22/18 minimum data set (MDS) assessment revealed, the resident had no memory problems, with a brief interview for mental status (BIMS) score of 15 out of 15. Resident required extensive assistance of one person with most activities of daily living. She was frequently incontinent of bladder and bowel. Resident was admitted with existing pressure ulcer to sacral region. 2.Wound care observation On 3/25/19 at 10:16 a.m. the resident was receiving wound care treatment that was provided by licensed practical nurse (LPN) # 1. The resident had an open area to her coccyx, approximately 1cm x1cm, with no drainage, and no discharge. The nurse cleaned the wound with a gauze that was soaked in normal saline, and applied an ointment ordered by physician. On the right lateral side of the knee he resident had red to blue abrasion area, approximately 1 cm x 1cm. The nurse stated it was an old skin condition. The resident also had multiple pieces of tape on her right arm. Resident said she had open areas there as well . The tape was removed by the nurse and three small open areas were observed under the tape. The nurse said the resident often scratched her skin and covered it with tape herself. 3. Record review a. Care plan The care plan, initiated 11/16/18 and revised on 11/16/18, identified the resident had self care deficit related to decreased functional activity tolerance and decreased strength. Interventions included therapeutic activities and to assist with daily hygiene, grooming, dressing, and oral care. The care plan, initiated 11/15/18 and revised 12/27/18, identified the resident was at risk for alteration in skin integrity related to impaired mobility and occasional incontinence. Interventions included to observe skin conditions and report abnormalities. Care plan did not mention that resident was admitted with existing pressure ulcer to sacral region. The care plan, initiated 12/28/18 and revised 2/21/19, identified resident had an open area to coccyx. Interventions included to administer treatment per physician orders, encourage and assist as needed to turn and reposition, use assistive devices as needed, provide pressure relieving cushion for recliner while up to prevent shearing, weekly skin audits, and wound team assessment b. Skin assessments Skin alteration records for March, 2019 read on the top do not use for pressure ulcers. It had recorded measurements of open area to coccyx, and was marked as trauma wound. No other skin alterations were recorded. c. Physician order Physician orders [REDACTED]. The nurses were to update the care plans, skin sheets, and progress notes on shower days and as needed. Progress notes reviewed for (MONTH) and (MONTH) 2019. There were no mention of the abrasion to the residents right lateral knee. The nursing staff failed to accurately and consistently document and monitor the residents compromised skin areas of concern. IV. Staff interviews The unit manager/RN #2 was interviewed on 3/26/19 at 9:38 a.m. She said the wound to the left leg for Resident #61 was initially observed on 2/13/19 and the foam dressing was applied to the wound. She said according to the physician orders [REDACTED]. She said the resident stayed in bed most of the time. Regarding Resident #105 skin assessments, she said the bruises were not mentioned on the skin sheets, they were only mentioned in progress notes and that was a facility protocol for documenting skin alterations. Abrasions and skin tears were monitored on paper skin sheets, pressure ulcers and deep tissue injuries (DTIs) were documented on the computer in push tool. She said she was following the skin protocol of the facility. Occupational therapist (OT) #1 was interviewed on 3/26/19 at 9:53 a.m. He said Resident #61 did not ambulate much during therapy sessions. He said the resident was using the hinge brace for her left knee, and there was a physician order [REDACTED]. He said the purpose of the brace was to limit flexion of the knee, and to stabilize it. He said hinge brace was necessary for ambulation, he said it was not necessary for the resident to wear the brace in bed. He said such braces were given to residents who may forget and get up from bed independently. He said Resident #61 was not able to get out of the bed independently due to her overall decline that persisted. He said it was an ortho physician order [REDACTED]. Nurse practitioner (NP) #1, was interviewed on 3/26/19 at 12:34 p.m. She said to her knowledge Resident #61 was wearing an immobilizer that should not be removed. She recalled that it was a request from the hospice team to remove the brace or to keep it open when resident was in bed. She said it was important to check for circulation, pain, skin breakdown under the brace. She said since the resident was bedridden it was acceptable to remove the brace while she was in bed. She said she was aware Resident #61 had wounds and was being followed by the wound team and the wound physician. She did not recall the specifics of the wounds as the wound care physician was involved with the resident. Physical therapist (PT) #1 was interviewed on 3/26/19 at 12:55 p.m. He said when he worked with Resident #61 she had a very slow progress due to her fracture, difficulty managing balance, and low motivation. He said Resident #61 did not ambulate for the first two weeks of her stay. In the last quarter of therapy, on one occasion she was able to ambulate with a lot of rest and assistance from two people. He said Resident #61 was wearing a brace that was supposed to be on all the time. He said that brace prevented the resident from bending her knee for more than 90 degrees, and to prevent dislocation of the fractured area. He said it was unusual to wear a brace at all times, considering that resident was not able to get out of bed independently and did not move her leg when she was in bed. He said he would not recommend wearing such braces at all times as it would put the resident at a high risk for skin breakdown. He said it was a physician order [REDACTED]. After he reviewed the discharge summary from the hospital, dated 1/22/19 and current physician orders, he said he was not able to locate anywhere in the residents file that the brace should have been on all the times. The primary care physician (PCP) for Resident #61 was interviewed over the phone on 3/26/19 at 2:44 p.m. He said he did not know much about the brace that Resident #61 was wearing. He said by reading his notes he could tell that the resident was wearing a brace on her left lower extremity due to tibial fracture. He said the nurses often reported to him about the wounds, but he does not recall any specifics about the wounds for Resident #61. He said he did communicate with other physicians involved in care when he felt it was necessary. He did not recall communicating with the orthopaedic physician or wound care physician regarding the resident ' s brace. He said in situations when resident ' s skin was compromised due to braces or other devices, the use of such devices should be evaluated. He did not recall being asked about hinge brace that resident was wearing or any skin condition that resident developed due to it. He said if it was brought to his attention that device was causing skin problems he would discuss it with the unit manager and if necessary would call the orthopaedic physician. The orthopaedic physician was contacted by phone on 3/26/19 at 3:09 p.m. She did not return the call. Unit manager/RN #2 was interviewed a second time on 3/25/19 at 4:50 p.m. She said the wound on Resident 61 ' s leg started as an abrasion that progressed to a bigger wound. She said as of today, 3/25/19 it was treated as unstageable wound. She said the resident used to wear a hinge brace that was not removable per physician's order [REDACTED]. She said she believed the resident developed wounds due to her overall declining health status. She provided a timeline of the events and stated that upon discovery of abrasions, the brace was padded. She was not able to provide written evidence that such treatment was done and that it was consistently implemented by the nurses. She was not able to locate the physician order [REDACTED].#61 to keep the brace on all the time. She said she did not recall having any conversations with primary care provider regarding the hinge brace for Resident #61. The director of nursing (DON) was interviewed on 3/26/19 at 4:46 p.m. She said she believed all necessary care was given to the resident. She said the reason for development of pressure injuries for Resident #61 were resident ' s comorbidities and overall decline in her condition. She pointed out that the resident went on hospice care (which was later revoked by the family), was treated for [REDACTED]. She said she did not recall having a conversation with any of the resident's physicians regarding the resident ' s hinge brace. Regarding skin assessment documentation for Resident #105. She said the bruises were not included on the skin sheets. Bruises were monitored in nurses notes only. She said abrasions and skin lacerations should be documented with measurements on the skin sheet and monitored daily. She said pressure ulcers and DTIs were documented in the electronic medical record push tool. Wound care physician was interviewed on 3/25/19 at 8:30 a.m. He said Resident #61 had a pressure related trauma wounds on her left lower leg. He said the resident was wearing a hinge brace that was rubbing against her skin and started the injury. He said when the wounds were brought to his attention the resident was no longer wearing hinge brace. Regarding DTI on the heel, he said it was caused by pressure. He said in order to develop a DTI pressure must be consistently present at least for several days. He said it was unlikely to develop a DTI over a period of one day.

Based on record review and interviews, the facility failed to provide necessary assessments and necessary care and services for one (#1) of three sample residents. The resident experienced several falls resulting in pain and the facility failed to thoroughly assess the resident to determine the cause for her ongoing pain. After the initial fall, 1/14/12, the resident experienced a decline in her activities of daily living functioning, her ability to retain urinary continence and continued to experience pain with minimal relief over several weeks. Specifically, the facility failed to ensure a thorough assessment was completed after a fall, assess the reasons for the resident's decline in function and continued complaints of pain for resident #1. Hospital records documented an x-ray, dated 2/14/12, revealed the resident had a fractured pelvis, hip and ribs. Cross reference F323 The findings include: 1. Resident #1, age 88, was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Resident Status The resident's most recent Minimum Data Set (MDS), dated [DATE], documented the resident scored 6 out of 15 on the cognitive assessment, indicating the resident had a moderate impairment. The MDS documented the resident required extensive assistance with all Activities of Daily Living, including bed mobility, transfers, and toilet use. The MDS also indicated the resident had falls prior to admission to the facility, and had falls after admission to the facility. The MDS documented the resident did not have pressure sores and was not at risk for developing pressure sores. b. Record Review The resident's progress notes documented a fall on 1/14/12. The resident complained of lower back pain and an x-ray of the resident's back and coccyx/tailbone was ordered. The X-ray revealed an osteoporotic compression of a few vertebrae. The progress notes documented the resident continued to complain of pain in her lower back; pain medication was administered and documented as effective. The progress notes documented the resident experienced another fall on 1/21/12; however no "obvious injuries" were noted. Another fall was documented on 1/22/12, again no injuries were noted. The progress notes documented the resident continued to complain of low back pain that was relieved by requested pain medication. The record revealed there were no further x-rays or other tests completed to assess the resident for injury. Another fall was documented in the progress notes on 2/3/12, "Resident was in bathroom . . . Resident complaining of back pain. She has been complaining of back pain consistently since her last fall. MD and (family member) notified . . ." The record revealed there were no x-rays or other tests completed to assess the resident for injury. The Progress notes continued to document the resident complained of pain which was relieved by pain medications, the resident's family requested some physical therapy intervention for the pain on 1/24/12, and the doctor was notified. On 2/12/12, "Resident complaining of pain this shift 6/10 with frequent administration of PRN pain medication. Resident cried out when touched. MD called . . . 0 S/S of injury noted." On 2/13/12, " . . . Resident refused to get OOB (out of bed) today; also refused shower. PRN pain medication x2 on 6-2 shift for 5/10 pain. Will continue to monitor." The progress notes documented the doctor visited later that day and ordered an x-ray of the resident's pelvis, physical therapy for back pain, and to discontinue occupational therapy. The X-ray report was received on 2/14/12, showing a fractured pelvis. The resident was sent to the hospital. Hospital Records documented the resident had a fractured pelvis, rib fractures (at least some of them old), and a [MEDICAL CONDITION]. The hospital documentation of the surgery to repair the [MEDICAL CONDITION] documented the hip had begun to heal in some areas, indicating the resident "likely fell about a month ago and had an unrecognized right proximal femur fracture. Radiographs were eventually obtained 2 days ago showing this fracture, although she has had some degree of hip pain for over a month." The Physical Therapy Weekly Summaries documented the resident was participating in physical therapy and that Contact Guard Assist was safe for the resident as on 1/9/12. After the resident's fall on 1/14/12, the physical therapy summary documented the resident was maximum assist with bed mobility, and would only stand, no longer ambulate. The weekly status documented on 1/30/12, "Pt has been reluctant to ambulate secondary to c/o (complaints of) pain in lumbar. Nrsng is aware and prn meds are given regularly. Pt has not been able to stand consistently as seen by only one time standing for <30 seconds. Pt is very unstable when standing. Pt refused to walk with this PTA (physical therapy assistant). X4 this week." The next entry dated 2/6/12 documented, "Pt conts (continues) to receive skilled PT services. Every day is a different scenario re: participation. This PTA has not been able to get pt out of bed. Pt refuses 4/5 x. Pts legs have given out during transfer from bed to wheelchair. Pt again refused to walk with the PTA C/o pain have been addressed with nrsng staff. Pt's deteriorating cognition is a hindrance." The physician progress notes [REDACTED]. -On 1/17/12, "Pt with fall on 1/14/12. Since then back pain. X ray done-old compression fx (fracture), no acute changes. Pt not walking and using w/c (wheelchair) since the fall. Nurses are using (pain medication) when she is awake. Per pt medication works, but does not last, nurses state she is asking about every 4 h(ours) for (pain medication)." "A/P: low back pain-muscle pain Cause of injury, fall- high fall risk, PT continues to work with pt (patient)" The resident's facility care plan, revised on 2/21/12, documented, "Pain-related to arm FX, rib, and Hip." Interventions included, "Administer pain medication as per MD and note the effectiveness, evaluate pain characteristics . . ." The Medication Administration Records (MAR) for 1/12 and 2/12 were reviewed. The pain assessment documented: -From 1/1/12 to 1/14/12, the resident consistently expressed pain of 0-4 out of 10 on the 6-2 and 2-10 shifts, and one report of a 6. The location of the pain was consistently reported as the resident's humerus. -From 1/14/12 to 2/14/12, the resident consistently expressed pain of 2-6 out of 10 on the 6-2 and 2-10 shifts. The location of the pain was consistently lower back. Although the facility addressed the resident's pain with medication, the facility did not assess the cause of the pain and did not address the cause of the resident's physical decline after the fall on 1/14/12. The facility obtained x-rays of the resident's back, however when the x-rays were negative, the facility did not pursue the origin of the pain. The resident was later diagnosed with [REDACTED]. c. Interviews The Director of Nursing (DON) was interviewed on 7/11/12 at 12:20 p.m. The DON stated the resident's pain was documented in the progress notes and pain assessments were completed on each shift. The DON stated the resident complained of back pain consistently, and did not complain of hip pain. The DON stated the resident's pain was controlled with PRN (as needed) medication, and because the medication was effective, there was no indication of a need for other medication. The DON stated the facility addressed the resident's pain and believed the pain was caused from a muscle strain in the resident's back. The DON stated the resident complained of an increase in pain in February that was not being controlled with the medication, so the x-rays were ordered. The DON stated the resident had been refusing therapy prior to the resident's falls (However, progress notes from therapy indicated the resident was participating until the fall on 1/14). A Certified Nurse Aide (CNA) familiar with the resident was interviewed on 7/11/12 at 1:50 p.m. The CNA stated the resident was in a lot of pain most of the time and the staff had to be very gentle and patient with her. The CNA stated the resident often refused to get out of bed, however the staff encouraged the resident to get up. The CNA also stated the resident was continent and able to make her needs known when the resident was first transferred from rehab, however the resident declined physically and became incontinent after the fall. A Licensed Practical Nurse (LPN) was interviewed on 7/11/12 at 2:16 p.m. The LPN stated the resident often stayed in bed because of pain. The LPN stated the pain medication seemed effective.