Coal Creek Post Acute & Assisted Living

Based on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care for Resident #65, Resident #62 and Resident #29, who were on enhanced barrier precautions (EBP).Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), retrieved on 8/25/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, It read in pertinent part,Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization, as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for enhanced barrier precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care, any skin opening requiring a dressing.I. Observations On 8/18/25 at 10:30 a.m. there was a sign on Resident #65's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/18/25 at 10:50 a.m. Resident #65, who had an indwelling urinary catheter was being assisted in the bathroom with transfer assistance and catheter care by registered nurse (RN) #1, certified nurse aide (CNA) #1 and CNA #3. RN #1 was wearing a protective gown and gloves. CNA #1 and CNA #3 were wearing gloves but were not wearing gowns.-CNA #1 and CNA #3 failed to don (put on) a protective gown prior to providing direct care for Resident #65. On 8/18/25 at 11:35 a.m. there was a sign on Resident #62's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/18/25 at 11:38 a.m. an unidentified nursing staff member and physical therapy assistant (PTA) #1 were assisting Resident #62, who had a surgical wound with staples on her left hip, with her clothing change and transfer to her wheelchair. The unidentified nursing staff member was wearing gloves but did not have a gown on. PTA #1 was not wearing a gown or gloves.-The unidentified nursing staff member failed to don a protective gown and PTA #1 failed to don gloves or a gown prior to providing direct care for Resident #62. On 8/19/25 at 9:00 a.m. there was a sign on Resident #29's door that indicated the resident was on EBP. The sign on the resident's door indicated gloves and a gown must be worn for resident care activities, including dressing, bathing/showering, transferring, linen changes, providing hygiene, changing briefs or assisting with toileting and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies and wound care.On 8/19/25 at 9:20 a.m. CNA #2 entered Resident #29's room and retrieved his morning meal tray. While CNA #2 was retrieving the meal tray, the resident, who had wounds on his legs, a colostomy and an intravenous line (IV), requested assistance with emptying his colostomy bag. CNA #2 donned gloves and proceeded to provide colostomy care. -However, CNA #2 failed to don a gown prior to providing direct care to Resident #29. II. Staff interviewsRN #1 was interviewed on 8/18/25 at 11:00 a.m. RN #1 said Resident #65 was on EBP because he had a superficial pressure wound on his buttocks and had an indwelling foley catheter. RN #1 said all staff should have donned a protective gown in addition to wearing gloves when providing direct care for Resident #65 in the bathroom. She said the reason staff should wear a gown and glove when providing care to the resident was because his Foley catheter and his wound made him highly vulnerable to getting an infection. CNA #1 was interviewed on 8/18/25 at 11:05 a.m. CNA #1 said she was usually informed by the RNs which residents were on EBP. CNA #1 said if a resident was on EBP, the PPE should be available and hanging on the back of the resident's room door. CNA #1 said Resident #65 was on EBP because he had a Foley catheter. She said she thought she did not need to wear a protective gown when assisting him in the bathroom because she was not touching his Foley catheter and was only helping with his transfer assistance. CNA #1 said she should have worn a gown and she would remember to do so the next time she was assisting a resident who was on EBP. CNA #1 said she thought the facility provided her with education on EBP but she was not completely sure.CNA #3 was interviewed on 8/19/25 at 10:42 a.m. CNA #3 said she did not know she needed to put on PPE when she was providing direct care for Resident #65. She said she was not informed by RN #1 that she needed to wear a protective gown. She said she assumed she only needed to wear gloves.CNA #2 was interviewed on 8/19/25 at 9:25 am. CNA #2 said she would obtain a shift- report from the outgoing CNA staff regarding which residents were on transmission-based precautions. She said she would ask the nurses to see what type of PPE needed to be used for each resident. She said EBP was needed to prevent the staff from giving the resident an infection. She said she only needed to wear a protective gown when she was emptying Resident #29's colostomy bag. Licensed practical nurse (LPN) #1 was interviewed on 8/19/25 at 3:29 pm. LPN #1 said residents who were on EBP had signage on the door indicating they were on EBP, along with the type of PPE staff was required to use inside the residents' rooms. She said nurses were additionally able to obtain the same information in the residents' medical records in order to relay the information to the CNAs. LPN #1 Said Resident #62 was on EBP because she had a surgical wound on her left hip. She said all nursing staff should wear a protective gown and gloves with any close-contact activities, including clothing changes and resident transfers.The director of nursing (DON) and the infection preventionist (IP) were interviewed together on 8/21/25 at 10:30 a.m. The IP said she had worked at the facility for two years and obtained her infection prevention certification in January 2025. She said she shared the IP role responsibilities with another staff member who was currently out of the building and unavailable. She said her role as IP consisted of antibiotics stewardship, providing staff education on infection control once a month during staff meetings, providing as needed one-on-one infection control education and providing new staff hire education on infection prevention methods. The DON said all staff were provided with education on the differences between contact precaution and EBP and advised on what PPE to use during which resident care activity. She said nursing staff should wear a gown and gloves with any close contact resident care activities, such as wound care, Foley catheter care and assisting the resident in and out of bed. The DON said Resident #29 had just finished a course of antibiotics because of his medical condition related to his motor vehicle accident. She said he had an IV, a colostomy, a Foley catheter and healing wounds all over his body from the accident. She said it was very important that the staff adhered to EBP to prevent any potential infections. The DON said it was important for all staff to adhere to the designated resident-specific precaution recommendations because the facility wanted to keep the residents safe from developing preventable infections. She said the facility did not want to be the cause of any infection. She said the potential negative outcome to the facility staff of not adhering to EBP could be the resident contracting MDROs and there was a high potential of spreading the infection to another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two (#29 and #62) of five residents reviewed for immunizations out of 36 sample residents.Specifically, the facility failed to offer Resident #29 and Resident #62 the COVID-19 vaccination. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC), COVID-19 guidelines (revised 1/7/25), retrieved on 8/25/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html. Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization, and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are age [AGE] and older, are at risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine.II. Resident #29 A. Resident status Resident #29, age less than 65, was initially admitted on [DATE] and readmitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included traumatic brain injury, chronic pain, open wound of the right hand, fracture of the left arm and fracture of the pelvis.The 8/1/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required substantial/maximal assistance with shower and bath, supervision/touch assistance with lower body dressing, and dependent with toileting hygiene. He required setup assistance with eating.The assessment did not indicate that the resident was ever offered the COVID-19 vaccine. B. Resident interviewResident #29 was interviewed on 8/19/25 at 9:05 a.m. He said he was admitted to the facility after a motorcycle accident. He said he did not remember being offered a COVID-19 vaccination from the facility and was unsure of his vaccination status.C. Record reviewReview of Resident #29's electronic medical record (EMR) on 8/21/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. III. Resident #62A. Resident statusResident #62, age greater than 65, was admitted on [DATE]. According to the August 2025 CPO, diagnoses included fracture of the right femur, joint replacement surgery, anemia, dementia, generalized weakness and cognitive communication deficit.The 8/19/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. She was dependent on staff for eating, toileting hygiene, showers/baths and upper body dressing. She required partial/moderate assistance with oral hygiene. The assessment did not indicate that the resident was offered the COVID-19 vaccine. C. Record reviewReview of Resident #62's EMR on 8/21/25 did not reveal documentation that the COVID-19 vaccine was offered or administered to the resident. D. Staff interviewsThe director of nursing (DON) and the infection preventionist (IP) was interviewed together on 8/21/25 at 10:30 a.m. The DON said the facility monitored and tracked the residents' immunizations status in the EMR. She said the facility offered and provided education to the residents regarding the COVID-19 vaccinations upon admission after review of their vaccination history. The DON said she did not have documentation indicating Resident #29 or Resident #62 were offered and declined the COVID-19 vaccination She said it was the admitting nurses responsibility to document in the resident's EMR if the resident refused the vaccination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#3, #28, #72 and #73) of 24 residents out of 36 sample residents reviewed. Specifically, the facility failed to:-Speak with Resident #3, Resident #28, Resident #72 and Resident #73 respectfully while providing care to the residents; and,-Ensure residents were not discussed by staff in areas where the conversations could be overheard by others.Findings include:I. Facility policy and procedureThe Dignity policy and procedure, revised August 2009, was provided by the nursing home administrator (NHA) on 8/21/25 at 12:30 pm. It revealed in pertinent part, Employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed about what rights and responsibilities he or she has; privacy and confidentiality and voice grievances and have the facility respond to those grievances.II. Resident #3A. Resident statusResident #3, age less than 65, was admitted on [DATE]. According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy, cerebral infarction (stroke), left-sided hemiplegia (paralysis of the left side of the body), depression, anxiety and insomnia. The 8/4/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with repositioning, transfers, toileting, dressing, hygiene and showering.B. Resident interviewResident #3 was interviewed on 8/20/25 at 12:53 p.m. Resident #3 said during the evening of 8/15/25, she tried to use her call light to call for assistance but the call light was out of reach of Resident #3's right side. Resident #3 said she called the facility using her cell phone in order to ask a staff member for help. Resident #3 said she called multiple times from 8:45 p.m. until 9:15 p.m. Resident #3 said registered nurse (RN) #5 answered the phone, spoke rudely to Resident #3 and told her to stop calling. Resident #3 said she did not file a grievance and did not notify the NHA or the director of nursing (DON) because she did not know that she could file a grievance. III. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 CPO, diagnoses included chronic kidney disease stage 3, osteoarthritis of the left knee, alcohol use with withdrawal delirium, polyneuropathy, anxiety and insomnia. The 8/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #28 required touching assistance with bathing and when ambulating with a walker.B. Resident interviewResident #28 was interviewed on 8/18/25 at 12:06 p.m. Resident #28 said she was waiting for RN #5 to bring her as needed medication for her pain on 8/16/25 at approximately 8:00 p.m. Resident #28 said she heard RN #5 talking loudly in the hallway calling somebody a drug addict. Resident #28 said she asked RN #5 if she was referring to Resident #28 when she said drug addict. Resident #28 said RN #5 replied to her that she was not talking to Resident #28 when she made that statement and RN #5 said she had a hallway full of drug addicts. Resident #28 said RN #5 was rude and dismissive when administering her medication.Resident #28 was tearful recalling the events of the evening (8/16/25) during the interview. Resident #28 said she reported the statements made by RN #5 to the DON on the morning of 8/17/25. Resident #28 said she thought the facility was looking into her concern, but she was not sure. IV. Resident #72A. Resident statusResident #72, age greater than 65, was admitted on [DATE] and discharged from the facility on 6/17/25. According to the June 2025 CPO, diagnoses included heart disease, diabetes type 2, chronic kidney disease stage 2, unspecified falls and syncope (fainting). The 5/29/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. Resident #72 required partial assistance with bathing, hygiene, dressing and footwear.B. Record reviewResident grievances were provided by the NHA on 8/21/25 at approximately 08:00 a.m. The resident grievances revealed Resident #72 filed a grievance to the DON on 6/2/25. The grievance revealed an unidentified nurse was argumentative with Resident #72 when discontinuing her intravenous (IV) infusion. When Resident #72 asked the nurse to clean her central IV line with alcohol instead of chlorhexidine (a potent, broad-spectrum antiseptic and disinfectant used to kill bacteria and other microorganisms). The grievance revealed Resident #72 said the nurse told her I'm a nurse and I know what I'm doing. The grievance revealed Resident #72 suffered blisters around the site of her central line after the use of chlorhexidine. The grievance documented the resolution to Resident #72's grievance was that the staff nurse was not to touch any intravenous infusions until additional education was completed and intravenous competency was demonstrated. -However, the grievance did not indicate if the inappropriate way the RN spoke to Resident #72 was addressed by the facility.V. Resident #73A. Resident statusResident #73, age greater than 65, was admitted on [DATE] and discharged from the facility on 7/10/25. According to the July 2025 CPO, diagnoses included wedge compression fractures of the T9 to T12 (thoracic) vertebra with routine healing, lower back pain, difficulty walking, unspecified lack of coordination, depression and insomnia. The 6/17/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. Resident #73 required substantial assistance with bathing, lower body dressing, footwear and toileting. Resident #73 required moderate assistance with hygiene, upper body dressing, repositioning and ambulating less than 10 feet.B. Record reviewResident grievances were provided by the NHA on 8/21/25 at approximately 08:00 a.m. The resident grievances revealed Resident #73 filed a grievance about the way a staff member spoke to her. The grievance revealed Resident #73 asked an unidentified certified nurse aide (CNA) to go slower when transferring from her wheelchair to the toilet and back to bed due to pain. The grievance revealed Resident #73 also asked for a second staff member to help with the transfer. The grievance revealed the unidentified CNA told Resident #73 other staff would not come down to help because Resident #73 was too difficult to work with. The grievance revealed the resolution for the grievance was to have the CNA work in a different hall. -However, the grievance did not indicate if the inappropriate way the CNA spoke to Resident #73 was addressed by the facility.VI. Staff interviewsThe DON and the regional director of clinical services were interviewed together on 8/20/25 at 1:48 p.m. The DON said she was aware of the allegations made by Resident #28. She said an investigation of the incident was being conducted. The DON said she interviewed Resident #28 and Resident #28 told her the care she received from RN #5 was rude but she was not tearful during the initial interview. The DON said she was not aware of the additional allegation regarding RN #5 from Resident #3. The DON said she planned to start an additional investigation and to ask all other residents to see if additional residents were affected by RN #5.

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination; and, -Ensure safe and appropriate storage of food items in the main kitchen walk-in refrigerator. Findings include:I. Failed to ensure ready-to-eat foods were handled in a sanitary mannerA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/25/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. (3-301.11)B. Facility policy and procedureThe Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure was received from the nursing home administrator (NHA) on 8/21/25 at 1:16 p.m. It read in pertinent part, Gloves are considered single-use items and must be discarded after completing the task for which they are used. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.C. ObservationsDuring a continuous observation of the lunch meal service on 8/20/25, beginning at 11:05 a.m. and ending at 12:09 p.m. the following was observed:At 11:44 a.m. cook (CK) #1 was preparing two grilled cheese sandwiches on the griddle. With gloved hands, CK #1 used one hand to stabilize the sandwiches on top of the spatula as he transferred them from the griddle to a cutting board. With the same gloved hands, CK #1 grabbed the handle of the dish heater and pulled out two plates. CK #1 used his gloved hand to stabilize the sandwiches as he cut them on the cutting board, then picked the sandwiches up with his gloved hands and placed them onto each plate.At 11:52 a.m. CK #2 was wearing a set of gloves. CK #2 used his gloved hand to adjust a piece of toast on a plate to make room for spaghetti noodles. CK #2 had previously handled meal tickets and serving utensils with the same gloved hands.-CK #2 did this two more times throughout meal service.At 11:58 a.m. CK #1 donned (put on) a pair of gloves and began preparing a cheeseburger. CK #1 retrieved a plastic bag of hamburger buns, opened the bag, and grabbed a bun using his gloved hand before placing it on a plate. CK #1 opened the walk-in refrigerator and retrieved a plastic package of cheese slices and two pieces of lettuce, holding the lettuce with the same gloved hand. CK #1 placed the lettuce leaves onto the hamburger bun, opened the plastic packaging for the cheese and retrieved a slice of cheese using his gloved hand.At 11:59 a.m. CK #2 was ladling spaghetti sauce onto a plate of noodles and got some of the sauce on the side of his hand. CK #2 wiped the sauce off of his glove onto the inner rim of the steam table bin containing spaghetti sauce. CK #2 had previously been handling meal tickets and serving utensils with the same gloved hands.At 12:02 p.m. CK #2 used his gloved hands to place the top bun of the cheeseburger onto the rest of the burger. CK #2 then used his gloved hand to stabilize the cheeseburger as he cut it in half. CK #2 was previously handling meal tickets and serving utensils with the same gloved hands.D. Staff interviewThe dietary manager (DM) was interviewed on 8/21/25 at 8:45 a.m. The DM said gloves should be changed from one job to the next with hand hygiene performed between glove changes. The DM said ready-to-eat foods should be handled with utensils and should not be handled by hand. II. Failure to safely and appropriately store food itemsA. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/25/25. It revealed in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location where it is not exposed to splash, dust, or other contamination. (3-305.11)B. Facility policy and procedureThe Kitchen Sanitization policy and procedure was received from the NHA on 8/21/25 at 1:16 p.m. It read in pertinent part, All counters, shelves and equipment are kept clean and maintained in good repair.C. ObservationsA tour of the main kitchen was conducted on 8/17/25 at 1:15 p.m. In the walk-in refrigerator, there was a patch of green-grey mold on the floor next to the door to the freezer, approximately six inches square. Two baking sheets, which held plastic containers of cheese shreds and packages of sliced cheese, had small scattered spots of mold along their inner edges and corners.On 8/20/25 at 11:15 a.m., during a second tour of the main kitchen, the baking sheets holding the cheese products had been cleaned. The patch of mold on the floor of the refrigerator was still present.On 8/21/25 at 8:40 a.m., during a final tour of the main kitchen, the patch of mold on the floor in the walk-in refrigerator was still present and unchanged.D. Staff interviewsThe DM was interviewed on 8/20/25 at 11:20 a.m. The DM said she had not seen the mold on the floor or on the baking sheets in the walk-in refrigerator. The DM said the dietary staff deep-cleaned the refrigerators once a month, during which time they took out all of the shelves and scrubbed the refrigerator floor. The DM said the staff were a bit late on cleaning that month because they had been short-staffed. The DM said she had experienced some issues with mold but the maintenance staff were working on trying to fix the fans in the refrigerator. The DM said she was not sure if maybe the issue was trapped deeper within the tubing and components of the refrigerator fans. The DM said their freezer had recently broken down and the ice had melted, so she thought the mold on the floor may have been from the ice melt in the freezer. The DM said she would work with the dietary staff that evening and scrub the floors in the fridge.-However, the patch of mold on the refrigerator floor was observed the following day (see observations above).The DM was interviewed a second time on 8/21/25 at 8:45 a.m. The DM said the issues with buildup on the floor were caused from the freezer breaking down. The DM said she thought the baking sheets on the shelves in the refrigerator were disrupting airflow and therefore causing buildup, so she said she was thinking of removing them and storing food directly on the shelves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews the facility failed to ensure accurate medical records were kept for one (#28) of five residents out of 36 sample residents reviewed. Specifically, the facility failed to maintain accurate records for Resident #28 of pain reassessments and foley catheter care in the electronic medical record (EMR). Findings include:I. Professional referenceAccording to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 261 and 1067. Assessment is a continuous process that occurs each time you interact with a patient. It involves the collection of new data. Reassessment is not the same as evaluating care or determining a patient's response to an intervention. Instead, it is the gathering of additional information to ensure that the plan of care is still complete, current, and appropriate. Analgesics should be initiated at the lowest effective dose and titrated to achieve pain control with minimal adverse effects; this requires frequent reassessment of patients for pain relief and side effects as doses are adjusted.II. Resident #28A. Resident statusResident #28, age [AGE], was admitted on [DATE]. According to the August 2025 computerized physician's orders (CPO), diagnoses included chronic kidney disease stage 3, osteoarthritis of the left knee, alcohol use with withdrawal delirium, polyneuropathy, anxiety and insomnia. The 8/17/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. Resident #28 required touching assistance with bathing and when ambulating with a walker.B. ObservationsDuring a continuous observation on /19/25, beginning at 8:16 a.m. and ending at 12:09 p.m., the following was observed:At 8:16 a.m. Resident #28's medication administration record (MAR) and treatment administration record (TAR) were incomplete. The documentation for indwelling catheter care was blank at the start of the observation. At 8:38 a.m. RN #2 administered as needed pain medication per the residents request. RN #2 asked Resident #28 to rate their pain on a scale of 1 to10 during the medication administration.At 11:16 a.m. Resident #28's MAR had completed documentation for the pain reassessment score after the as needed pain medication and Resident #28's TAR had completed documentation for indwelling catheter care.-However RN #2 had not returned to Resident #28's room since the time of the pain medication administration and no staff entered the resident's room to provide catheter care. C. Resident interviewResident #28 was interviewed on 8/19/25 at 11:39 a.m. Resident #28 said nobody cleaned her indwelling catheter that morning (8/19/25). Resident #28 said she did not remember seeing RN #2 after RN #2 administered her pain medication this morning and nobody asked her to reassess her pain after taking the pain medication. Resident #28 said the staff reassessed her pain about half of the time she received as needed pain medication. D. Record reviewThe progress note, dated 8/19/25 at 9:35 a.m. documented Resident #28 rated her pain as a 3 out of 10on follow up assessment.-However, based on observations and the interview with Resident #28, this assessment did not occur.E. Staff interviewsThe director of nursing (DON) and the regional director of clinical services were interviewed together on 8/21/25 at 10:59 a.m. The DON said accurate medical records inform staff of the effectiveness of the current interventions in the plan of care. The DON said the time the indwelling catheter care was documented in the TAR was 8:47 a.m. The DON said the time the task was marked as completed in the TAR did not necessarily reflect the time the care occurred. The DON said the nursing staff had to provide multiple avenues of care and may not have documented care at the specific time it was completed. The DON said staff were encouraged to document care as accurately as possible. The DON said in regards to the pain medication reassessment, the DON said she planned to provide individual education to RN #2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#4) of three residents out of nine sample residents were free of significant medication errors.
Specifically, the facility failed to ensure Resident #4 was administered his Parkinson's medication per the physician orders.
Findings include:
I. Professional reference
According to the carbidopa/levodopa dosing instructions, retrieved from https://www.goodrx.com/carbidopa-levodopa/dosage on 11/21/24, A combination of two medications: carbidopa and levodopa. Levodopa replaces dopamine, which improves symptoms of Parkinson's disease. And carbidopa helps levodopa stick around longer in the body.
If you miss a dose of carbidopa/levodopa, take the medication as soon as you remember. But if you remember when you' re already close to taking your next dose, skip the missed one.
Don' t take more than one carbidopa/levodopa dose at a time. Doubling up on doses can be dangerous and lead to more side effects, such as movement problems and mood changes.
Taking too much carbidopa/levodopa can be dangerous and increase your risk of side effects. These side effects may include low blood pressure, a fast heartbeat and confusion.
According to the carbidopa-levodopa dosing guidelines, retrieved from https://www.drugs.com/medical-answers/carbidopa-levodopa-3562239/ on 11/21/24, It is important to adhere to the schedule closely, and it is recommended that you take the medication at the same time each day.
II. Facility policy and procedure
The Administering Medication policy, revised 2019, was received from the nursing home administrator (NHA) on 11/13/24 at 9:08 a.m. It documented in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Medication errors are documented, reported and reviewed by the quality assurance and performance improvement (QAPI) committee to inform process changes and or the need for additional staff training. Medications are administered within one hour of their prescribed time, unless otherwise specified.
III. Resident #4
A. Resident status
Resident #4, age [AGE], was admitted on [DATE] and discharged on 8/1/24. According to the July 2024 computerized physician orders (CPO), diagnoses included Parkinson's disease (brain disease causing uncontrollable movements and difficulty with motor function), acute respiratory failure and difficulty in walking.
According to the 7/21/24 minimum data set (MDS) assessment Resident #4 was cognitively intact with a brief interview for mental status score of 15 out of 15. She required partial/moderate assistance with hygiene, dressing and transferring.
B. Record review
Review of Resident #4's July 2024 CPO revealed the following physician order:
Carbidopa-Levodopa oral tablet disintegrating 25-100 milligrams (mg), give one tablet by mouth four times a day for Parkinson's, ordered on 7/15/24, administer at 8:00 a.m., 12:00 p.m., 4:00 p.m. and 8:00 p.m.
A review the July 2024 medication administration record (MAR) revealed on 7/30/24Resident #4 did not receive Carbidopa-Levodopa at 8:00 a.m., 12:00 p.m., or 4:00 p.m. per the physician's order. The MAR was marked with the number nine for those times, which indicated other and to see the nursing progress note.
A nursing progress note from 7/30/24 at 7:24 a.m. revealed Resident #4 was noted to be out of Carbidopa-Levadopa. The nurse called the pharmacy and the pharmacy noted it was in process and would be delivered to the facility that day. The nurse urged the importance of the medication to the pharmacist due to the amount of medication the resident took.
A nursing progress note from 7/30/24 at 3:23 p.m. revealed the medication delivery made to the facility did not contain Resident #4's Carbidopa-Levadopa. The nurse spoke to the pharmacy and the pharmacy said they would send it out as STAT (immediately). The nursing unit manager was made aware of the concern at this time.
-The nursing staff failed to audit the cart and reorder the medication before the medication ran out.
-The nursing staff failed to order the medication as STAT once they noticed it was missing.
-There was no documentation that the resident's physician was notified after Resident #4 missed three doses of the Carbidopa-Levadopa.
-There was no documentation that the nurse monitored Resident #4 for symptoms that she may have experienced while missing the medication.
IV. Staff interviews
Registered nurse (RN) #1 was interviewed on 11/13/24 at 1:50 p.m. RN #1 said it was the responsibility of the floor nurses to audit the medication cart each shift and order medications as needed. She said if a medication was due to run out within two to three days, she would reorder it. She said the pharmacy the facility worked with delivered the medications the day after ordering.
RN #1 said the medication could also be ordered as STAT and it would arrive within an hour and a half. She said Parkinson's medications should be administered per the physician order. She said if the medication was missed, she would notify the provider and monitor the resident for increased Parkinson's symptoms such as agitation and tremors. She said the number nine on the MAR indicated other and to see the nursing progress note.
The director of nursing (DON), the assistant director of nursing (ADON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 3:10 p.m.
The ADON said it was the expectation for the nursing staff to audit the medication carts on the night shift and reorder any medication that was due to run out in the next five days. She said the pharmacy had a four hour window to deliver medications orders as STAT, but they typically came within an hour. She said if a medication administration was missed for a resident, the process was to notify the provider, notify the unit manager and DON and order the medication as [NAME] She said the nurse should monitor the resident for any symptoms the resident had due to missing the medication. She said the symptoms should be documented in the resident's medical record. She said the number nine on the MAR indicated other and to see the nursing progress note. She said there should be a nursing progress note associated with each documentation of a nine in the MAR.
The RCR said there was no documentation that the nurse notified the provider of Resident #3's three missing doses of Carbidopa-Levadopa.
The consultant pharmacist was interviewed on 11/13/24 at 4:09 p.m. The pharmacist said the medication was important to take according to the physician's orders unless the resident was experiencing any clinical side effects.
She said if the resident missed doses, it could worsen the Parkinson's effect and the resident's motor abilities could not have been managed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for two (#9 and #8) of three residents out of nine sample residents.
Specifically, the facility failed to ensure Resident #9 and Resident #8 received medications as scheduled according to the physician's orders.
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, page 606-607, retrieved on 11/21/24, It read in pertinent part, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication.
II. Facility policy and procedure
The Administering Medication policy, revised 2019, was received from the nursing home administrator (NHA) on 11/13/24 at 9:08 a.m. It documented in pertinent part, Medications are administered in a safe and timely manner and as prescribed. Medication errors are documented, reported and reviewed by the quality assurance and performance improvement (QAPI) committee to inform process changes and or the need for additional staff training. Medications are administered within one hour of their prescribed time, unless otherwise specified.
III. Resident #9
A. Resident status
Resident #9, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included Alzheimer's dementia and hypertension (high blood pressure).
The 11/11/24 minimum data set (MDS) assessment the resident had short term and long term memory deficits and was severely impaired with daily decisions per staff assessment.
The assessment indicated Resident #9 was receiving an antidepressant, opioid (pain medication) and hypoglycemic medications (used to lower blood sugar).
B. Observations
Licensed practical nurse (LPN) #1 was observed during medication administration on 11/13/24 at 9:35 a.m. She was preparing medications for Resident #9. She put two 500 milligrams (mg) tablets of Tylenol and squirted Voltaren gel into another cup.
She approached the resident at the table near the nurses station and administered the medications at 9:50 a.m.
C. Record review
The November 2024 medication administration record (MAR) for Resident #9 revealed that all of Resident #9's medications were scheduled for 8 a.m.
-Resident #9 received her medications one hour and 50 minutes past its scheduled time and 50 minutes after the allowed medication administration window (see observations above).
IV. Resident #8
A. Resident status
Resident #8, age greater 65, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included osteomyelitis (bone infection) and type 2 diabetes.
The 10/10/24 MDS assessment revealed Resident #8 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15.
The assessment indicated Resident #8 was receiving an antipsychotic (class of drugs used to treat mental disorders), an antibiotic and an antiplatelet medication (used to prevent blood clots).
B. Observations
LPN #1 was observed during medication pass on 11/13/24 at 10:00 a.m. S was preparing medications for Resident #8. She put the following medications in the cup:
-B-complex vitamin one tablet;
-Finasteride (urinary retention medication) five mg one tablet;
-Aspirin 81 mg one tablet;
-Lactobacillus tablet (probiotic);
-Quetiapine (antipsychotic medication) 12.5 mg; and,
-Omeprazole (used to treat gastroesophageal reflux disease) 20 mg.
She administered the medications at 10:06 a.m.
C. Record review
The November 2024 MAR for Resident #8, revealed that the B-complex, Finasteride and aspirin were scheduled for 8:00 a.m. The lactobacillus, quetiapine and the omeprazole were scheduled to be administered at 9:00 a.m.
-Resident #8 received the B-complex, Finasteride and Aspirin two hours and six minutes past the scheduled time and one hour after the medication administration window.
-Resident #8 received the lactobacillus, quetiapine and the omeprazole one hour and six minutes past the scheduled time and six minutes after the medication administration window.
V. Staff interviews
The director of nursing (DON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 4:30 p.m. The RCR said the nursing staff had a one hour window (one hour before and one hour after scheduled time) to administer medications. She said she reviewed the time stamps on the morning medications for Resident #9 and Resident #8 and said their morning medications were administered late. She said the medications were administered late because the morning nurse called off and did not come to work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for one (#3) of three residents reviewed out of nine sample residents.
Resident #3 was admitted to the facility on [DATE] for rehabilitation after surgery on her back. Upon admission, the resident was assessed for fall risk and was identified as a high risk for falls. However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3.
On 10/12/24 Resident #3 sustained a fall which resulted in a laceration to her head and required transportation to the emergency department for further evaluation and staples to close the laceration.
Findings include:
I. Facility policy and procedure
The Fall Management policy, reviewed September 2012, was provided by the nursing home administrator (NHA) on 11/13/24. The policy revealed the facility would identify each resident who was at risk for falls, would plan the care and implement interventions to manage falls. Residents who were at risk for falls, would have interventions to manage falls. The facility would manage falls by providing an environment that was free from potential hazards.
II. Fall investigation
The 10/12/24 fall investigation for Resident #3 was provided by the NHA on 11/13/24 at 11:00 a.m.
Review of the fall investigation revealed Resident #3 was found on the floor near her bathroom. The resident said she walked to the hallway and asked for help but the girl told me to do it myself. The resident returned to her room where she later was found on the floor with a laceration to her head. Resident #3 was transported to the emergency department for further evaluation.
The investigation included an interview with certified nurse aide (CNA) #2 who said she assisted Resident #3 to the bathroom and back to her room. CNA #2's written statement indicated Resident #3 continued to say that she was going to fall while CNA #2 was in the bathroom with her.
The investigation did not include an interview with the nurse or manager on duty at the time of the incident.
The investigation included interviews with three other staff members who were not present during the incident.
III. Resident #3
A. Resident status
Resident #3, age greater than 65, was admitted on [DATE] and discharged home on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included compression fracture of the fourth thoracic vertebrae, diabetes, difficulty walking, communication deficit, lack of coordination and congestive heart failure.
The 10/15/24 minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score was not conducted. The resident did not display any behaviors or rejection of care.
A 10/12/24 nurse progress note revealed the resident was alert and oriented to person, time, place and situation.
The assessment documented Resident #3 was independent with all activities of daily living (ADL).
B. Record review
Per the functional assessment completed on 10/11/24, Resident #3 required assistance with ambulation to the bathroom.
The 10/11/24 fall risk assessment revealed Resident #3 was at risk for falls.
-However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3.
Per the 10/12/24 daily skilled note, the resident had difficulty walking due to compression fracture.
The 10/12/24 nurse progress note documented Resident #3 was found sitting on the floor at 6:05 a.m. and the resident was noted to have a laceration 2 centimeters (cm) by 0.5 cm by 0.1 cm bleeding down her hair and onto her chest. When the resident was asked what happened, Resident #3 said she asked a girl (CNA #2) for help and was told she could do it herself. Resident #3 said she took the walker and went to the bathroom. The resident did not know what happened and said she just fell backwards. A physician's order was obtained to send the resident out to the emergency department for evaluation.
The 10/12/24 emergency department records revealed Resident #3 was admitted after a fall at the nursing facility where she asked for help and was refused. The resident sustained a head trauma with a laceration that was secured with two staples and a dressing. The resident was discharged back to the nursing facility the same day (10/12/24).
IV. Staff interviews
The director of nursing (DON), the assistant director of nursing (ADON) and the regional clincial resource (RCR) were interviewed together on 11/13/24 at 3:30 p.m.
The ADON said she received a call from the floor nurse on 10/12/24. She said the floor nurse reported to her that Resident #3 had a fall. She said the floor nurse told her that Resident #3 was assisted to the bathroom by CNA #2. The ADON said she was told Resident #3 later approached CNA #2 again when she was giving a report to another CNA. She said the resident was told to return to her room where she was later found on the floor in the bathroom. The ADON said she did not participate in the formal investigation of the incident.
The DON said she did not recall the incident on 10/12/24 and she was not sure if she was included in the investigation. She said every resident was assessed upon admission for fall risk and baseline care plans were initiated to ensure the safety of residents.
-The DON was unable to say why Resident #3's baseline care plan initiated on 10/11/24 did not identify the resident was at risk for falls or include person-centered interventions to prevent falls for the resident.
The RCR said Resident #3's initial assessment for fall risk should have triggered the baseline care plan for falls and should have included person-centered interventions for the resident.
The physical therapist (PT) was interviewed on 11/13/24 at 4:15 p.m. The PT said Resident #3 participated in therapy and reached her full potential at the time of her discharge from the facility on 11/3/24. He said, upon admission, the resident required one-person assistance with transfers. He said the resident was admitted after back surgery and it was very difficult for the resident to get up. He said she required maximum assistance getting off the bed or chair and assistance of one person when ambulating.
The NHA was interviewed on 11/13/24 at 4:45 p.m. The NHA said he completed the investigation for the 10/12/24 incident involving Resident #3. He said CNA #2 was suspended from her duties during the investigation and later was dismissed as she did not return the facility's calls. The NHA said he could not substantiate that neglect had occurred for Resident #3 because he could not prove that CNA #2 refused to provide assistance to the bathroom for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to promote and maintain resident dignity by providing care in a dignified, respectful and individualized manner for three (#1, #5 and #6) of three residents out of 12 sample residents.
Specifically, the facility failed to:
-Ensure Resident #1 and Resident #6 were treated with dignity and respect when they asked for care assistance; and,
-Ensure Resident #5, a resident with a diagnosis of Alzheimer's disease, was provided a dignified experience of receiving sufficient care to maintain good personal health and hygiene.
Findings included:
I. Facility policy
The Dignity policy, revised February 2021, was provided by the corporate nurse consultant (CNC) on 8/27/24 at 11:10 a.m. It read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.
Individual needs and preferences of the resident are identified through the assessment process.
Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility.
When assisting with care, residents are supported in exercising their rights. For example,
residents are; groomed as they wish to be groomed (hairstyles, nails, facial hair).
The Resident Rights policy, revised December 2016, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, Employees shall treat all residents with kindness, respect and dignity. The residents' rights include a dignified experience.
The Activities of Daily Living (ADL), Supporting policy, dated 2001, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
II. Resident #1
A. Resident status
Resident #1, age [AGE], was admitted on [DATE] and discharged on 7/29/24. According to the July 2024 computerized physician orders (CPO), diagnoses included diabetes and congestive heart failure.
The minimum data set (MDS) assessment was not completed.
The nursing admission assessment dated [DATE] documented Resident #1 was alert and oriented to person, place, time and situation and was calm and cooperative. The resident was motivated to participate in rehabilitation services and needed assistance with ADLs, including transferring, toileting, dressing and hygiene. The resident was incontinent of bladder and usually had daily bowel movements.
B. Record review
A review of Resident #1's electronic medical record (EMR) revealed the resident's baseline care plan had not yet been started and there was no CNA task record or [NAME] (abbreviated plan of care for the CNA).
-The CNC confirmed the facility did not have a [NAME] for Resident #1.
A social services note, dated 7/29/24 at 11:18 p.m., documented Resident #1 said he wanted to leave the facility due to the caregiver neglecting to provide timely assistance for him to use the bathroom.
The facility investigation dated 7/29/24 documented that the resident asked his certified nurse aide (CNA) #2 for assistance to use the bathroom to have a bowel movement and CNA #2 told him to remain in bed, go to the bathroom in his brief and she would clean him up afterward. The resident insisted he be taken to the bathroom. CNA #2 finally took the resident to the bathroom. Staff interviews revealed Resident #1 waited so long for the staff to act that he thought he was not going to make it to the bathroom. The resident was unhappy with the way he was treated and told staff that he was leaving and going home. Resident #1 called the police, rolled himself outside of the facility and was taken to the hospital by ambulance transport.
The facility's investigation concluded CNA #2 did not respond to Resident #1 in a dignified and respectful manner when she told him to go to the bathroom in his brief instead of providing him timely assistance to use the toilet as he asked.
III. Resident #5
A. Resident status
Resident #5, age greater than 65, was admitted on [DATE] and discharged on 8/11/24. According to the August 2024 CPO, diagnoses included Alzheimer's disease, overactive bladder and depression.
The MDS assessment was not completed.
The nursing admission summary dated [DATE] revealed the resident was alert and oriented to person only. The resident was incontinent of bowel and bladder and dependent on staff to complete ADLs and used a mechanical lift for transfers.
B. Resident representative interview
Resident #5's legal representative was interviewed on 8/26/24 at 10:33 a.m. The representative said she had talked to the facility during Resident #5's admission and several times afterward about the resident's care choices. The representative said Resident #5 spent a lot of time in bed but had requested that staff get her up before lunch so she could spend time with family when they visited. The representative said the resident also requested staff get her up so she could participate in Sunday church services, the one activity she enjoyed. She said there were several occasions when the family would visit and find Resident #5 with poor hygiene and wearing the same clothing as the day before. She said this was out of character for Resident #5.
The resident's representative said she was in the facility to see the resident every day at different times of day and she found her mom in poor condition on several occasions making her fear for the resident's health. She said Resident #5 had a pressure injury when she admitted and it started worsening. She said if Resident #5 did not get proper hygiene and hydration assistance, her wounds would worsen.
The resident's representative said Resident #5 had always had good hygiene and it was important to her. The representative said Resident #5 was in a total state of helplessness and was dependent on staff to provide good care for her overall wellbeing and happiness. She said staff did not take the time to change soiled linens, provide timely incontinence care or remove the resident's soiled clothing to be laundered. The representative said this left Resident #5 and her room with a foul odor. The resident's representative said it was disappointing to see the resident in a soiled state.
The resident's representative said, on 8/4/24, she provided the facility a detailed letter of the family's observations and concerns with action items (interventions) that she and Resident #5 would like to have provided for the resident but she said things still were not corrected by the facility.
The resident's representative said her concerns for the resident's well-being deepened when she learned that the nursing home administrator (NHA) had not been provided a copy of her grievance letter and was not informed of her request to meet with the leadership team to discuss the details of her grievance letter.
The resident's representative said it was not long after she gave the facility the letter that the family decided to remove Resident #5 from the facility's care. She said they moved Resident #5 out of the facility on 8/11/24, 16 days after she was admitted to the facility.
C. Record review
A care conference summary dated 8/2/24 revealed the resident and her legal representative were in attendance at the care conference, as were the facility's interdisciplinary team (IDT) members, including the director of nursing (DON) and the social services director (SSD). The summary documented the family planned for Resident #5 to remain in the long-term care setting and for the resident's husband to move to the facility's on-site assisted living community.
The psychosocial mood care plan initiated on 8/2/24 revealed Resident #5 was at risk for decreased psychosocial well-being adjustment issues and emotional distress. The goal was for the resident to have no decline in mood or behavior that prevented her from functioning in her daily activities. Interventions included assessing the resident's preferences and choices with activities and encouraging involvement and encouraging friends and family support/visits.
A nursing note dated 8/4/24 documented the resident's legal representative voiced concerns about the resident's care. The representative voiced concerns that, despite a request at a care conference, the resident was not up for church that morning (8/4/24) and she had the same shirt on from 8/2/24 (Friday). The representative was additionally concerned because the resident had not had a shower since her admission to the facility on 7/26/24 and soiled laundry was left on the shower floor.
A care conference summary dated 8/8/24 revealed Resident #5, her legal representative and another family member were in attendance at the care conference, as were the facility's IDT members, including the DON, the SSD and the activities director (AD).
The care conference summary documented the resident's representative and the other family member brought up concerns about the resident's personal and environmental hygiene. The representative said she had arrived at the facility to assist Resident #5 with the noon meal and found the resident in a darkened room and still in bed. The representative said she had asked the facility staff, upon the resident's admission to the facility, to make sure the resident was up and dressed by 11:00 a.m. so she could eat her meal while seated in her chair and not in bed.
According to the care conference summary note, the representative's concerns included finding Resident #5 being left in heavily soiled undergarments and smelling strongly of urine. The sheets of the resident's bed were also stained and soiled with urine. The representative said the resident's bedding was covered with food crumbs from the resident being assisted to eat while in bed. Additionally, the representative was concerned because the resident had not been showered.
The IDT's plan for the resident's care was to schedule management follow-up to make an observation of Resident #5 every morning at 9:00 a.m. to ensure the resident was provided assistance to meet her care needs.
A comprehensive skin evaluation assessment dated [DATE] documented the resident was placed on a two-hour check and change schedule.
-The care plan was not updated to reflect the two-hour check and change intervention.
The facility investigation dated 8/14/24 documented that, after investigating the resident's legal representative's concerns, the facility substantiated that CNA #1 failed to provide the resident with a hygienic environment when they left soiled laundry in and around the resident's room. The facility separated from CNA #1 and did not schedule her for additional shifts.
CNA #1 was interviewed on 8/14/24. CNA #1 said she checked on Resident #5 in the morning assisted her with breakfast and changed the resident. She did not prove the time that the care was completed. CNA #1 said she continued with rounds assisting her other residents and came back to Resident #5's room to find the family present. CNA #1 said the family was very upset by the condition of Resident #5 and by the presence of a soiled laundry being found on the floor of the resident's shower.
-The facility's interview with CNA #1 did not provide answers and details about the exact nature of why the family was upset, the complaint the family voiced and the exact condition of how the resident was found. The investigation did not establish a timeline of events with CNA #1 and failed to provide any substantial evidence about CNA #1's knowledge of the resident's routine or care needs.
IV. Resident #6
A. Resident status
Resident #6, age less than 65, was admitted on [DATE] and discharged on 7/5/24. According to the July 2024 CPO, diagnoses included amputation between the left hip and knee, diabetes and pressure-induced deep tissue injury.
The 6/10/24 MDS assessment documented the resident had intact cognition with a BIMS score of 15 out of 15. The resident was dependent on staff for toileting hygiene and bathing and substantial assistance with dressing. The resident was frequently incontinent of bladder and occasionally incontinent of bowel.
B. Record review
The facility investigation dated 7/10/24 documented Resident #6 filed a grievance on 7/3/24 that when she asked her assigned CNA (CNA #3) to assist her in changing her soiled brief, CNA #3 told her You do not need me to change your diaper, you can do it your (expletive word) self. CNA#3 was removed from the care of Resident #6 and another CNA took over the resident's care and provided ADL assistance and emotional support.
The investigation documented there were no witnesses to the exchange between CNA #3 and Resident #6 and the facility concluded it was a He said, she said situation.
-However, the facility terminated CNA #3 when the investigation revealed there were four other times in the prior two weeks that CNA #3's conduct caused several other residents to request CNA #3 not to provide care for them.
V. Interviews
A frequent visitor (FV) to the facility was interviewed on 8/26/24 at 2:47 p.m. The FV said she had concerns about the way residents in the facility were treated. She said residents complained that they were not always treated respectfully and others had to wait a long time for care to be completed. The FV said residents had reported that staff did not address them directly and walked away from them in the middle of a conversation when they were asking for staff assistance. The FV said she brought resident-voiced concerns, as well as her observed concerns, to the leadership team and found that it took a long time for the facility to address resident grievances.
The FV said the new NHA seemed to be taking things more seriously than the previous NHA and some things had improved. She said several of the problematic staff were no longer working in the facility.
Resident #9 was interviewed on 8/26/24 at 3:41 p.m. Resident #9 said she had just filed a grievance concern earlier today (8/26/24) because of the disrespectful way one of the CNAs made her feel. Resident #9 said she never knew how she would be treated from day to day. She said there were good CNAs and then other CNAs were disrespectful and rough with care assistance.
Resident #9 said some CNAs would drop off her meal tray and walk out quickly; never speaking to her to see if she needed anything. She said other CNAs would walk away mid-conversation and she did not get what she needed. Resident #9 said today (8/26/24), a CNA came in to take her to the bathroom and she hurriedly assisted her to the toilet. The CNA never apologized or said anything about it.
The NHA was interviewed on 8/27/24 at 8:12 a.m. The NHA said he was new to the facility and started working as the NHA on 7/10/24. The NHA said, after becoming familiar with the facility's operating practices, he implemented several quality measures and improvement projects. He said a couple of areas of focus included developing an orientation binder for agency staff that they were to read before working in the facility. He said the binder would provide agency staff information on basic facility policy, expectations for resident care and following the resident care plan. The NHA said. initially, agency staff were not provided access to the resident's plan of care. He said the DON and assistant director of nursing (ADON) would be responsible for reviewing admission intake information and providing a report to staff on the day of admission to ensure appropriate care was provided for all residents.
The NHA said he recognized the need for staff to be better educated on the importance of treating every resident with dignity and respect while meeting the resident-assessed care needs and preferences.
The NHA said he was saddened when he learned about the care concerns brought forward by several residents and their families. He said poor quality of care should not be the resident experience.
The NHA said it frustrated him that members of leadership had not brought the concerns of Resident #5's family members to him when they first voiced grievances because he believed the concerns could have been fixed and the resident could have been happy living in the facility. The NHA said he did not learn of the family's concerns until a few days before the resident was discharged .
The NHA said once he started to investigate resident care concerns and grievances, he realized the leadership team needed to make some changes in the staff's approach to resident care and staff's understanding of the facility's expectations to ensure that all resident care needs were met in a dignified and respectful manner.
The NHA said he called a mandatory all-staff meeting last night (8/26/24) and early this morning (8/27/24), which was the first of many training sessions where staff would be educated on the importance of customer service and resident care. The NHA said that staff who did not follow facility policies for resident care would be removed from employment.
The DON, the unit manager (UM) and the CNC were interviewed on 8/27/24 at 10:56 a.m. The UM said every unit had a nurse-to-nurse report sheet that was updated each shift and the CNAs had access to the residents' [NAME]. The UM said the floor nurse should have updated the CNA assigned to Resident #1 about his care needs, especially since the resident had been newly admitted .
The DON said she expected the nursing staff to be compassionate, provide good customer service and treat the residents like family. The DON said the facility would be educating staff on the expectations of good customer service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #133
A. Resident status
Resident #133, over the age of 65, was admitted on [DATE]. According to February 2024 CPO, diagnoses included hypoglycemia, chronic pain, protein calorie malnutrition, weakness, rheumatoid arthritis and cognitive communication deficit.
The 2/23/24 MDS assessment had not been completed for the resident at the time of the survey.
B. Resident observation
On 2/26/24 at 9:44 a.m. Resident #133 was sitting on her bed. She was rearranging her items on the bedside table.
-At 9:46 a.m., dietary aide (DA) #1 arrived in the resident's room to pick up a breakfast tray. Resident #133 asked DA #1 for a cup of warm coffee. DA #1 told the resident to ask her nurse and walked away from the resident's room without providing the cup of warm coffee.
C. Resident interview
Resident #133 was interviewed on 2/27/24 at approximately 10:14 a.m. Resident #122 said she did not receive the cup of warm coffee she asked for after finishing her breakfast the previous day (2/26/24). The resident said she asked the wrong staff member and she was disappointed that she could not get a cup of warm coffee when she needed it.
D. Staff interviews
DA #1 was interviewed on 2/27/24 at 10:22 a.m. DA #1 said she was informed she was not to provide any resident services including providing water and coffee for any of the residents in the facility. DA #1 said she informed the nursing staff about the resident's request for warm coffee, however, she did not recall who she talked to about the resident needing assistance with a cup of warm coffee. DA #1 said she did not know if the resident received the coffee.
Licensed practical nurse (LPN) #3 was interviewed on 2/27/24 at 10:31 a.m. LPN #3 said she was not informed about the resident needing assistance with getting a cup of coffee. She said the dietary staff usually would notify the floor nurse about a resident's request and ask if they could assist.
Unit manager (UM) #1 and the ADON were interviewed together on 2/28/24 at 10:15 a.m. The ADON and UM #1 both said they did not understand the reason DA #1 told Resident #133 to ask her nurse as the resident was recently admitted to the facility and did not know who the nurse was.
The ADON said every staff member, regardless of position, had been trained to be able to assist residents. The ADON said she would ensure staff education was provided to prevent the incident from occurring again.
UM #1 said DA #1 should have informed the nurse or the CNA about the resident's request for coffee.
Based on observations, record review and interviews, the facility failed to ensure residents were treated with dignity and respect for two (#12 and #133) of five residents reviewed for dignity and respect out of 18 sample residents.
Specifically, the facility failed to:
-Ensure Resident #12 was assisted during meal times in a dignified manner; and,
-Ensure Resident #133 was treated with dignity and respect when she requested a cup of coffee.
Findings include:
I. Facility policy
The Dignity policy, revised February 2021, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.
Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice.
II. Resident #12
Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs).
The 2/14/24 minimum data set (MDS) revealed the resident was unable to complete the brief interview for mental status (BIMS). A staff assessment of the resident's cognitive status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares.
A. Observations
On 2/26/24 at 9:03 a.m., Resident #12 was sitting in the dining room. Two plates with pureed food were in front of her on the tray, covered with plastic.
At 9:10 a.m., certified nurse aide (CNA) #1 brought three plastic cups, one with apple juice, one with lemonade and one more with an unidentifiable liquid and placed them on the table in front of the resident. An Ensure (a nutritional supplement) was observed on the tray as well.
At 9:16 a.m., CNA #1 opened the Ensure and poured it into a cup. She proceeded to mix part of Resident #12's pureed food into the Ensure.
-CNA #1 did not call the resident by her name during the meal and she did not converse with the resident.
At 9:35 a.m., CNA #1 got up to answer a call light. She returned to the resident at 9:38 a.m. and offered the resident a mixture of the Ensure and pureed food.
At 9:41 a.m., CNA #1 left to find a nurse for another resident.
At 9:42 a.m. she returned and offered Resident #12 the mixture of Ensure and pureed food.
At 9:43 a.m., CNA #1 left to answer a call light.
At 9:48 a.m. she returned and offered the resident the Ensure/pureed food mixture, apple juice, and lemonade. The resident refused.
At 9:50 a.m., Resident #12's tray was taken away.
At 12:27 p.m., lunch was delivered to Resident #12 in the dining room. Her lunch consisted of two plates of pureed food covered with plastic, applesauce, an Ensure supplement and chocolate cake in a cup.
CNA #1 attempted to assist the resident with the meal but the resident appeared sleepy and was sitting with her eyes closed.
At 12:36 p.m., CNA #1 offered a drink to the resident and the resident opened her eyes. CNA #1 mixed the Ensure supplement with the pureed dish in a cup and gave it to the resident.
At 1:15 p.m. the resident was taken to her room.
-CNA #1 did not interact with Resident #12 when she was assisting with meals. She did not call the resident by her name and did not talk to the resident when she got up in the middle of assisting the resident with her meal to go answer call lights.
B. Resident representative interview
Resident #12's representative was interviewed on 2/26/24 at 1:15 p.m. The resident's representative said the resident got very little social interaction from the staff. She said the resident was nonverbal and it was important for the staff to converse with her. However, she said she did not see staff talk with the resident while they were assisting her with her meals.
C. Staff interview
The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said mixing Ensure and pureed food together was not the resident's preference. The DON and ADON said CNA #1 had not treated Resident #12 with dignity. The DON and ADON said staff was expected to treat all residents with respect and dignity and converse with every resident during resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (#12) of five residents reviewed for range of motion out of 18 sample residents.
Specifically, the facility failed to ensure Resident #12 was assessed for a restorative program for her contracted right hand.
Findings include:
I. Facility policy
The Prevention of Decline in Range of Motion policy, revised March 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, The facility in collaboration with the medical director, director of nurses, and as appropriate, physical/occupational therapy consultant shall establish and utilize a systematic approach for prevention of decline in range of motion, including the assessment, appropriate care planning, and preventative care.
II. Resident status
Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs).
The 2/14/24 minimum data set (MDS) revealed this resident had severe cognitive impairment with a brief interview for mental status was unable to be completed. It was documented that cognitive skills for daily functioning were severely impaired. There were no behaviors or refusals of care documented. She required extensive assistance and was dependent on staff for all cares. The assessment coded the resident as not having an upper extremity impairment.
-However, according to observations and interviews (see below) she did have an upper extremity impairment.
The assessment did not code the resident as having therapy or restorative services.
III. Observations
Resident #12 was observed on 2/26/24 at 9:03 a.m. She was sitting in a geri chair in the dining room holding a towel roll in her right hand.
Resident #12 was observed again on 2/26/24 at 1:00 p.m. Staff were changing her brief and put a stuffed animal in her right hand once she was back up in the geri chair.
-Although Resident #12 had items in her right hand during the observations, there was no formal restorative program in place for her contracture (see interviews and record review below).
IV. Resident's representative interview
Resident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she had requested restorative therapy upon admission. She said she had not witnessed the resident receiving therapy. She said the nursing staff sometimes put towel rolls in her contracted hand.
V. Record review
-The comprehensive care plan, initiated on 2/9/24 and revised on 2/14/24, did not mention the resident's contracture. There were no listed interventions in place.
VI. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 2/27/24 at 4:00 p.m. She said Resident #12 had a contracture to her right hand and she was unable to move it on her own. She said the nursing staff put a towel in her right hand to prevent the contracture from worsening. She said there was currently no formal restorative therapy program.
The director of rehabilitation (DOR) was interviewed on 2/28/24 at 12:03 p.m. She said there was currently no restorative program in place for long term care residents. She said the facility started accepting long term care residents about two months ago. She said contracture care was important because it helped maintain the ability to care for oneself. She said contractures could be very painful and appropriate care could help to alleviate the pain. She said every resident should be assessed for contractures and providing flexion, extension and splints to contracted areas in part of the treatment.
The director of nursing (DON), assistant director of nursing (ADON) and NHA were interviewed on 2/29/24 at 1:45 p.m. They said the facility currently did not have a restorative therapy program in place and they should have a program in place. They were aware of Resident 12's contracture and failed to provide her with appropriate treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#137 and #191) of five residents reviewed for supplemental oxygen use out of 18 sample residents.
Specifically, the facility failed to obtain a physician's order for the administration of oxygen for Resident #137 and Resident #191.
Findings include:
I. Facility policy
The Oxygen Administration policy, revised October 2010, was provided on 2/27/24 by the nursing home administrator (NHA). It read in pertinent part, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician's order for this procedure and review the physician orders or the facility protocol for oxygen administration.
II. Resident #137
A. Resident status
Resident #137, over age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included atherosclerotic heart disease, systolic congestive heart failure, and hypertension.
According to the 2/21/24 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 required limited assistance with bed mobility, grooming, and toileting, and one-person assistance with transfers.
The resident's assessment was not coded for the use of oxygen therapy.
B. Resident observations and interview
On 2/26/24 at 9:27 a.m., Resident #137 was sitting on her bed with a nasal cannula receiving oxygen through her nostrils. The resident's oxygen concentrator was set to 3 liters of oxygen per minute (LPM).
Resident #137 said she did not normally require the use of oxygen, however, she said her oxygen saturation level (level of oxygen in the blood) dropped from 90 percent (%) to 81% that morning (2/26/24). She said the nurse put her on oxygen to get her oxygen saturation levels back up above 90%.
On 2/26/24 at 2:15 p.m., Resident #137 was sleeping in her bed. She continued to have an oxygen nasal cannula in her nostrils and she was receiving oxygen at 3 LPM.
C. Record review
-The comprehensive care plan, initiated on 2/19/24, did not identify that the resident required the use of oxygen.
-There were no interventions included for oxygen therapy. The care plan did not include signs and symptoms to monitor for the use of oxygen.
-The February 2024 CPO did not include a physician's order to administer oxygen.
-Nursing progress notes written on 2/17/24 and 2/27/24 documented the resident did not require oxygen.
D. Staff interviews
Licensed practical nurse (LPN) #2 was interviewed on 2/27/24 at 3:20 p.m. LPN #2 said Resident #137 was not receiving oxygen therapy until the day before (2/26/24)when the resident's oxygen saturation levels dropped below 90%. She said Resident #137 received continuous oxygen at 3 LPM throughout the rest of the day. LPN #2 said she notified the resident's physician about the incident but forgot to request an order for the continued use of oxygen for the resident.
Certified nurse aide (CNA) #2 was interviewed on 2/28/24 at 10:30 a.m. CNA #2 said Resident #137 did not normally use oxygen. The CNA said she did not know the reason the resident was on continuous oxygen. She said she had never seen the resident on oxygen since the resident was admitted to the facility.
The assistant director of nursing (ADON) was interviewed on 2/29/24 at 2:00 p.m. The ADON said there should be a physician's order for the use of oxygen for every resident who required oxygen therapy. The ADON said she did not know why LPN #2 did not obtain a physician's order for Resident #137's oxygen after she had identified the resident needed oxygen. The ADON said too much oxygenation could slow breathing and heart rate to dangerous levels which could result in death. The ADON said the facility was revising the oxygen administration protocol including providing education to the nursing staff regarding obtaining physician's orders when a resident needed oxygen.III. Resident #191
A. Resident status
Resident #191, age [AGE], was admitted on [DATE]. According to the February 2024 CPO, diagnoses included aftercare following right hip joint replacement surgery, nausea and tachycardia (heart rate of more than 100 beats per minute at rest).
The 2/24/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required moderate assistance of one to two staff members with transferring, toileting and walking.
B. Resident observations and interview
On 2/26/24 at 9:41 a.m., Resident #191 was in her room. An oxygen concentrator was continuously providing her with 2.5 LPM of oxygen through a nasal cannula in her nostrils.
Resident #191 said she was admitted to the facility on [DATE] from the hospital for physical and occupational therapy after having elective hip surgery. She said the hospital attempted to discontinue the use of supplemental oxygen twice and were unsuccessful so she was admitted to the facility with oxygen. She said prior to having surgery she was not using an oxygen concentrator at home and she was unsure why there was a continued need for it at the facility or how long she was expected to use it.
On 2/27/24 at 1:37 p.m., Resident #191 was in her room. She continued to have a nasal cannula in her nostrils and the oxygen concentrator was providing her with 2.5 LPM of oxygen.
On 2/28/24 at 9:30 a.m., Resident #191 was again in her room with the oxygen concentrator continuously providing her 2.5 LPM of oxygen through the nasal cannula.
C. Record review
The 2/24/24 facility admission note revealed Resident #191 admitted from the hospital on three LPM of oxygen through a nasal cannula following right hip replacement surgery.
-Review of Resident #191's February 2024 CPO revealed there was not a physician's order for the administration of oxygen.
The 2/26/24 physician's progress note revealed Resident #191 had a new need for oxygen use after surgery related to acute respiratory failure and the resident's respiratory status was to be monitored and the oxygen weaned as tolerated.
The progress note further indicated Resident #191's oxygen use was decreased to 2 LPM from 3 LPM.
-However, the facility failed to have an order for the use of oxygen to include monitoring and weaning as tolerated.
-Additionally, Resident #191's comprehensive care plan did not include a care plan focus for the use of oxygen.
On 2/28/24, during the survey, the following physician's order was entered, in pertinent part, into Resident #191's electronic medical record (EMR):
Oxygen at 2 liters (L) a minute via (through) nasal cannula due to post surgical hypoxia (low levels of oxygen in your body tissues). Attempt oxygen titration as able, respiratory therapist to evaluate and treat one time only for hypoxia.
-However, the resident's care plan was still not updated to include the use of oxygen.
D. Staff Interviews
Registered nurse (RN) #1 was interviewed on 2/28/24 at 9:58 a.m. RN #1 said Resident #191 was using 2.5 LPM of oxygen and she knew this because she had just taken her vital signs. She said supplemental oxygen was considered a medication and required a physician's order. RN #1 was unable to find an order for the use of oxygen in the EMR for Resident #191.
Unit manager (UM) #1 was interviewed on 2/28/24 at 10:08 a.m. UM #1 said oxygen was considered a medication and should have a physician's order for use. She was unable to find an order for the use of oxygen listed in the EMR for the resident, nor was she able to identify a diagnosis it was being used for. UM #1 was able to locate an admitting report sheet from 2/24/24 indicating the use of 3 LPM of oxygen for Resident #191. She did not know why the resident was using 2.5 LPM instead of 3 LPM or if she could be weaned off the oxygen. UM #1 said the facility had a respiratory therapist on staff who could work with the physician regarding the appropriateness of oxygen use for Resident #191.
The ADON was interviewed on 2/29/24 at 2:29 p.m. The ADON said it was concerning Resident #191 was using oxygen without a physician's order or a diagnosis. She said there was not an order for the respiratory therapist to evaluate and treat the resident for oxygen use and a care plan had not been initiated for the resident's use of oxygen. She said oxygen use was considered a medication and should have a physician's order for use and a care plan in place if a resident was receiving oxygen. The ADON said the facility needed a better system in place to ensure physician orders were obtained for the use of oxygen and that a care plan was initiated for the use of oxygen. She said the facility started an audit on 2/28/24 to ensure other residents who were receiving oxygen had physician orders and a care plan for the use of oxygen in place.

Based on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms.
Specifically, the facility failed to:
-Ensure medication storage refrigerators were within acceptable parameters for proper medication storage;
-Ensure medication storage refrigerator temperatures were monitored and documented consistently;
-Ensure a Schedule IV controlled medication was properly stored in a locked, permanently affixed compartment in the medication storage refrigerator; and,
-Ensure expired medications were properly disposed of.
Findings include:
I. Facility policy
The Storage of Medications policy, revised November 2022, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the proper pharmacy or destroyed. Schedule II-V controlled medication are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications.
The Storage of Medications Requiring Refrigeration policy, revised November 2022, was received from the NHA on 2/29/24 at 1:03 p.m. The policy read in pertinent part, It is the policy of this facility to assure proper and safe storage of medications requiring refrigeration and to prevent the potential alteration of medication by exposure to improper temperature controls. 'Refrigerated' refers to temperature maintained between 36-46 degrees Fahrenheit (F).
Temperatures should be monitored daily to ensure proper temperature control and documented on the temperature log with date, time, and signature of the person performing the check clearly written.
II. Observations
On 2/29/24 at 10:00 a.m., the west hallway medication storage room was observed with licensed practical nurse (LPN) #4. The medication storage refrigerator contained vaccines and insulin.
-The medication storage refrigerator thermometer read 48 degrees F, which was above the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F.
On 2/29/24 at 10:15 a.m., the east hallway medication storage room was observed with registered nurse (RN) #1.The medication storage refrigerator contained a lockbox of emergency medications. The medications in the box included Humulin 70/30 insulin, a Lantus Solostar insulin pen, Humulin N insulin, Humulin R insulin, two lorazepam (a Schedule IV controlled medication used to treat anxiety) injectable syringes and a lorazepam multi-dose vial.
-The emergency medication box was not locked and had a label on it which indicated the medication kit expired in January 2024.
-The lorazepam, a Schedule IV controlled substance, was not stored in a locked, permanently affixed compartment in the medication storage refrigerator.
-The medication storage refrigerator thermometer read 30 degrees F, which was below the acceptable parameters for safe refrigerated medication storage of 36 degrees to 46 degrees F.
-The temperature logs for the medication storage refrigerator revealed several missing dates of documentation for the months of December 2023, January 2024 and February 2024.
III. Staff interviews
Registered nurse (RN) #1 was interviewed on 2/29/24 at 10:20 a.m. RN #2 said controlled medications were supposed to be kept under two locked systems. She said the consulting pharmacy was responsible for collecting expired medications and disposing of them properly.
The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 2/29/24 at 10:43 a.m. She said controlled medications should be stored under a double lock system. She said the refrigerator temperatures were inappropriate for storing medications safely. She said if controlled medications were stored in the medication storage refrigerator they must be in a place permanently affixed to the refrigerator. She said the facility's pharmacy was responsible for tracking and disposing of expired medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received and the facility provided food that accommodated resident preferences for one (#12) of three residents reviewed for food preferences out of 18 sample residents.
Specifically, the facility failed to ensure Resident #4 was provided with a vegetarian diet per her preference.
Findings include:
I. Facility policy
The Resident Food Preferences policy, revised July 2017, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modification to diet will only be ordered with the resident's or representative's consent. Nursing staff will document the resident's food and eating preferences in the care plan.
II. Resident status
Resident #12, age over 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included dementia and pulmonary hypertension (high blood pressure in the lungs).
The 2/14/24 minimum data set (MDS) assessment revealed the resident was unable to complete a brief interview for mental status (BIMS). The staff assessment for mental status revealed the resident's cognitive skills for daily functioning were severely impaired. She required extensive assistance and was dependent on staff for all cares.
III. Observations
On 2/26/24 at 9:03 a.m., Resident #12 was sitting in her wheelchair at a table in the dining room. There were two plates of pureed food on a tray in front of her. The plates were covered with plastic. The resident's meal ticket documented the resident was on a puree diet and thickened liquids.
-The puree food on the plates was not labeled to indicate what each food item was.
-The resident's meal ticket did not document what food the resident received for breakfast.
-The meal ticket did not indicate Resident #12 was to receive a vegetarian diet.
On 2/26/24 at 12:27 p.m., Resident #12 was sitting in the dining room for lunch. There were two plates with pureed food covered with plastic on the table in front of the resident.
-The puree food on the plates was not labeled to indicate what each food item was.
-The resident's meal ticket did not document what food the resident received for lunch.
-The meal ticket did not indicate Resident #12 was to receive a vegetarian diet.
On 2/29/24 at 12:45 p.m., Resident #12 was sitting in the dining room when her lunch was delivered. The food in the dishes delivered to the resident were labeled as beef pot pie, beans and bread.
-The resident's meal ticket indicated she was to receive a vegetarian diet, however, the resident was served beef pot pie for lunch.
-The resident's meal ticket did not document what food the resident received for lunch.
IV. Resident's representative interview
Resident #12's representative was interviewed on 2/26/24 at 1:00 p.m. She said she the resident had been assessed for dietary preferences. The representative said she told the facility's registered dietitian (RD) that the resident preferred a vegetarian diet. She said the facility frequently served the resident food which was inconsistent with a vegetarian diet.
V. Record review
Review of Resident #12's nutrition care plan, revised 2/14/24, revealed she was at a nutritional risk related to hospice. Interventions included providing a diet per physician order, dietary supplements as ordered, monitoring skin for signs of breakdown and for the registered dietitian (RD) to reassess as indicated.
-There was no intervention for the resident's food preferences documented on the care plan.
-The care plan did not document the resident was vegetarian.
VI. Staff interviews
The dietary manager (DM) was interviewed on 2/28/24 at 4:30 p.m. The DM said Resident #12t probably received the main dish listed on the menu every day for lunch. He said the resident was not verbal and her meals were communicated by her representative. The DM said he did not know who had contacted the representative for the resident's preferences or where resident's preferences were documented. He said he was not sure what the resident's diet preferences were.
The DM said if the resident preferred a vegetarian diet, she should probably receive the main dish option without the meat. He was not sure if Resident #12 was offered a protein substitute as an alternative to the meat portion of the menu. The DM said he did not have a vegetarian menu and it was improvised for every meal.
Licensed practical nurse (LPN) # 4 was interviewed on 2/29/24 at 12:50 p.m. LPN #4 looked at Resident #12's meal ticket and said she was not sure what resident received for lunch because her food items were not listed on the meal ticket.
After looking at the resident's food tray which was labeled, LPN #4 said the resident was served pureed beef pot pie, pureed beans and pureed bread. LPN #4 said she was not aware the resident was vegetarian.
The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 1:45 p.m. The DON and ADON said staff should follow residents' preferences for their diet. The DON and ADON said Resident #12 should be receiving a vegetarian diet if that was her preference and the vegetarian diet preference should be included on the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (#3, and #9) of five residents out of 18 sample residents.
Specifically, the facility failed to ensure transmission-based precautions were implemented for Resident #3 and #9.
Findings include:
I. Facility policy
The Transmission-Based (Isolation) Precautions policy, undated, was received from the nursing home administrator (NHA) on 2/29/24 at 1:03 p.m. The policy stated in pertinent part, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission. Contact precautions refers to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact with the resident of the resident's environment.
When implementing transmission-based precautions, the facility will consider the following: the identification of resident risk factors that increase the likelihood of transmission, the provision of a private room, cohorting residents with the same pathogen, and sharing a room with a roommate with limited risk factors.
Residents on transmission-based precautions should remain in their rooms except for medically necessary care.
Healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment.
Contact precautions are recommended for multi-resistant organisms, infection or colonization.
II. Resident #3
A. Resident status
Resident #3, under the age of 65, was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included infection following a procedure and a deep surgical incision site and methicillin-resistant staphylococcus aureus (MRSA) infection (highly contagious infection on the skin).
The 2/19/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required partial/moderate assistance for activities of daily living (ADL) which included dressing, toilet transferring and standing.
B. Observations
On 2/26/24 at 10:30 a.m., Resident #3 was sitting in her wheelchair in the hallway outside her room. Licensed practical nurse (LPN) #1 was preparing the resident's intravenous (IV) antibiotic infusion and hooked it up to her central line (a tube utilized for the administration of fluids or medications which is surgically placed in the neck, groin, chest or arm and can remain in place longer than a standard IV) in the hallway. Resident #3 remained in the hallway for the entire IV administration of her antibiotic.
-LPN #1 wore gloves to administer the IV medication, however, she did not put on a gown.
On 2/27/24 at 1:45 p.m., Resident #3 was in her room. LPN #1 gathered supplies for Resident #3's IV antibiotic infusion and entered the resident's room. She set up the IV antibiotic and attached it to the resident's central line.
-LPN #1 failed to put on a gown or gloves when she set up Resident #3's IV antibiotic infusion
-There was no isolation cart with personal protective equipment (PPE) in it outside of Resident #3's room.
-There was no sign on Resident #3's door which informed staff the resident was on transmission-based precautions or what type of PPE should be worn when working with the resident.
III. Resident #9
A. Resident status
Resident #9, age [AGE], was admitted on [DATE]. According to the February 2024 CPO, diagnoses included fracture of the neck and pressure injuries to the chin and back of the head.
The 11/28/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was dependent on staff for most ADLs.
B. Record review
The wound care note by the wound care physician, dated 12/20/23, revealed the resident's wound on her chin had a MRSA infection.
C. Observations
Wound care observations for Resident #9 were completed on 2/29/24 at 9:30 a.m. The wound care was completed by wound care nurse (WCN) #1.
-WCN #1 did not put on a gown before performing wound care for Resident #9, despite the resident having a MRSA infection in the wound on her chin, which required contact precautions, including the use of a protective gown.
WCN #1 entered the room, placed an Ipad (tablet computer) on the resident's table, donned gloves and prepared supplies for the wound. He approached the resident, removed the dressing on the right side of her chin and disposed of the dressing in the trash. The dressing was saturated with yellow drainage.
WCN #1 soaked a gauze pad in a wound cleanser solution and used the gauze pad to clean the wound. After cleaning the wound, he picked up the Ipad from the table, logged in, and took a picture of the resident's wound.
-WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad.
WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the wound.
-WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound.
After applying the clean dressing to the wound, WCN #1 removed his gloves. He applied clean gloves and started the wound care for the second wound on the back of the resident's head.
-WCN #1 did not perform hand hygiene prior to starting wound care on the resident's second wound.
WCN #1 removed the soiled dressing, which was saturated with yellow drainage, from Resident #9's wound on the back of her head. WCN #1 proceeded to pick up his Ipad and took a picture of the wound.
-WCN #1 did not change his gloves or perform hand hygiene before picking up the Ipad.
WCN #1 returned the Ipad to the table and proceeded to apply a clean dressing to the resident's head wound.
-WCN #1 did not remove his gloves or perform hand hygiene prior to applying the clean dressing to the wound.
IV. Staff interviews
LPN #2 was interviewed on 2/28/24 at 8:47 a.m. She said she was not aware of any resident on transmission-based precautions. She said she was not aware of any resident with an active MRSA infection. She said residents with MRSA were placed on contact precautions, which included a gown and gloves. LPN #2 said residents on contact precautions should have an isolation cart outside their room and a sign on the door to stop anyone who entered the room to see the nurse before entering.
The director of nursing (DON), assistant director or nursing (ADON), and NHA were interviewed on 2/29/24 at 11:07 a.m. The ADON said she was serving as the facility's infection preventionist. She said any resident with an active MRSA infection or a history of the infection were placed on contact precautions. This included wearing a gown, gloves, mask, and goggles or a face shield if splashing was a risk. She said residents on contact precautions should have an isolation cart outside their room with PPE in it. She said there should also be a stop sign on the resident's door stopping anyone from entering without checking with the nurse on duty. She said the facility had an adequate supply of PPE. The ADON said she was unaware of Resident #3's MRSA infection.
The ADON said it was inappropriate to set up and run an antibiotic in the hallway for a resident on transmission-based precautions. She said this was because of the potential to spread the infection to other staff members and residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#102) resident of three residents reviewed for dignity out of 24 sample residents.
Specifically, the facility failed to:
-Address resident in her preferred way; and
-Provide Resident #102 with a dignified dining experience in her room while she was eating lunch.
I. Resident #102
A. Resident status
Resident #102, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), pertinent diagnoses included lumbar fracture, multiple rib fractures and dementia without behaviors.
The 11/14/19 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. She required limited assistance of one person with most activities of daily living (ADLs), and supervision with meals.
Resident #102 did not exhibit any behaviours and did not resist the care.
B. Observations
Resident was observed on 11/21/19 at 1:17 p.m. She was assisted by certified nurse aide (CNA) #1 to her chair for lunch. After CNA was done assisting the resident, she said: Here we go, sugar. Do you need anything else?. Resident said no, and CNA left the room.
Resident #102 was sitting at the table, eating lunch. Her room had a strong smell of urine. Open plastic bag with dirty laundry was observed on the floor next to the entrance.
C. Resident interview
Resident was interviewed on 11/21/19 at 1:27 p.m. She said she did not like being called sugar because she was not that sweet. She said she did not know why CNA called her sugar, and said she would prefer to be called by her name.
II. Staff interviews
CNA #1 was interviewed on 11/21/19 at 1:30 p.m. She said she called everyone sugar because all residents liked that and it made them feel good. She said she did ask every resident if they were ok with her calling them sugar and they all liked that.
Registered nurse (RN) #1 was interviewed on 11/21/19 at 1:35 p.m. She was interviewed in resident ' s room. She said room had a strong odor of urine that probably was coming from the open bag of dirty laundry on the floor. She said CNAs were responsible for bagging laundry and moving it to dirty laundry room. She said dirty laundry should not be left on the floor and especially when a resident is eating.
Assistant director of nursing (aDON) was interviewed on 11/25/19 at 2:31 p.m. She said it was not appropriate to call residents sugar or honey or any other names except their real name. She said it was not a respectful was to call a resident. She said residents should be called by their names unless they request to use any other name. She said all dirty laundry should be removed from the room as soon as it was bagged.
III. Facility follow-up
On 11/26/19 at 2:47 p.m. facility submitted an email stating that Resident #102 was interviewed by facility staff and reported to them that she was treated with respect and dignity during her stay.
However, the facility did not submit any evidence of education that was given to staff members regarding dirty laundry handling, dignity, or respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #27
A. Resident status
Resident #27, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnosis included femur fracture.
The 11/5/19 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no memory problems, she did not experience delusions and hallucinations. Resident required extensive assistance of two people with most activities of daily living.
B. Resident interview
Resident #27 was interviewed on 11/19/19 at 2:29 p.m. She said since her arrival to the facility she had received one shower and one bed bath. She said her preference was to receive a shower three times a week and physician cleared her for showers a long time ago.
Resident #27 said, CNAs would come and say they will go check to see if anyone was available to give a shower, and did not come back. She said the ultimate response from CNAs and nurses was if we have time we can do it, but apparently they never have time. (Cross-referenced F725-insufficient staffing).Resident #27 said she end up asking her occupational therapist (OT) to assist her with showers and OT helped her.
C. Record review
The care plan for activities of daily living, initiated 11/7/19 with no revision date, identified the resident required assistance with bathing related to recent hospitalization. There were no interventions specific for bathing, such as preferred times and days.
According to the 10/29/19 preference sheet completed on admission, Resident #27preferred to receive showers three times a week.
According to the shower records for November 2019, the resident did not receive any showers in November 2019.
According to OT notes dated 11/16/19 resident said she has never received a shower during her stay at the facility. Resident was assisted by OT with shower on 11/16/19.
V. Resident #29
A. Resident status
Resident #29, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnosis included acute respiratory distress, and heart failure.
The 1/6/19 minimum data set (MDS) assessment revealed, the resident was cognitively intact with a brief interview for mental status (BIMS) score of seven out of 15. He was documented as he had no memory problems, he did not experience delusions and hallucinations. Resident required limited assistance of one person with most activities of daily living.
B. Resident interview
Resident was interviewed on 11/19/19 at 11:22 a.m. He said he received his second shower yesterday, and it was given to him by OT. He said his preference was to receive a shower every day, or at least every other day. He said every time he asked CNAs for showers they say not today because they are too busy. He said sometimes he felt sorry for the CNA because he can see how hard they work when they don ' t have enough help and he can understand why they can ' t find any time for him. He said he believed this facility was very understaffed and CNAs did not have enough help.
C. Record review
The care plan for activities of daily living, initiated 11/7/19 with no revision date, identified the resident required assistance with bathing related to limited mobility. The interventions included assistance of one person with bathing. There were no specific interventions related to residents preference of time and days.
According to the 10/29/19 preference sheet completed on admission, Resident #29 preferred to receive showers three times a week.
According to the shower records for November 2019, the resident did not receive any showers in November 2019.
VI. Resident #93
A. Resident status
Resident #93, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included unspecified fracture of lower end of right ulna, chronic kidney disease, stage 3, osteoporosis affecting left nondominant side, history of transient ischemic attack (TIA) and cerebral infarction, difficulty walking, and generalized muscle weakness.
The November 2019 activities for daily living (ADLs) care plan identified the resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, transfer, locomotion, and toileting related to a recent fall resulting in a fracture.
B. Resident and family interview
Resident #93 was interviewed on 11/20/19 at 10:00 a.m. during the resident group interview. According to the resident, he has had only one shower/bath since admission to the facility on [DATE]. The resident said he has not been offered, or given the choice for additional showers. The resident said he was not told of a bathing schedule. He said his family also expressed a concern for the lack shower/bathing opportunities.
Resident #93 was interviewed on 11/25/19 at 12:12 p.m. The resident was in his room, in a wheelchair reading a paper set on his bedside table. The resident had a slight odor of urine. The paper, placed in front of the resident, was identified as a bathing preference sheet. The resident said he just received a shower schedule that would allow him to have showers three days a week. He said he did not refuse showers. He said staff would only assist with cleansing after toileting. He said he would be happy if staff would provide him a shower three times a week.
The daughter of Resident #93 was interviewed on 11/25/19 at 12:16 p.m. She said she and her family were very concerned about the lack of offered bathing and felt it had been a big problem. She said on admission, she was told that the facility had only a staff member available to give showers twice a week. She said she was told he could have a shower on Sunday and Wednesday based on the staff schedule. The daughter said she would often come to the facility to see if Resident #93 was offered a shower.
She said, after frequent inquiries, he only received a shower on 11/7/19. She said she asked why he was not getting showers, and was told he refused and the facility could not force him to bathe. The daughter said she has not seen or been told by Resident #93 that he refused to bathe. The daughter said she had not seen a bathing preference schedule until the facility presented it to her and Resident #93 on 11/25/19. She said she would hope the facility would follow through with the planned three times a week schedule.
C. Record review
The November 2019 bathing record for Resident #93 identified the resident received a shower on 11/7/19. The record indicated on 11/7/19, was the only recorded bath/shower between 11/3/19 and 11/20/19. According to the record, all other dates between 11/3/19 and 11/20/19 were not applicable.
-The record did not show the resident received a bath, or a bed bath. The record did not show the resident was unavailable for a bath/shower, or refused a bath/shower between 11/3/19 and 11/20/19.
The weekly bath and skin report identified the resident had a shower on 11/21/19.
The task list report, initiated on 11/3/19, read the resident bathing was scheduled on Tuesdays, Thursdays, and Saturdays.
A bathing preference sheet, provided to the resident and signed by his daughter on 11/25/19, identified the resident wanted showers three days a week.
The November 2019 ADL care plan short term goal indicated the resident's ADL care
needs will be anticipated and met throughout the next review period.
-The care plan did not indicate the resident had a behavior of refusing ADL or bathing care.
The November 2019 preference care plan read it was important to the resident to have an opportunity to engage in daily routines that are meaningful relative to his preferences. According to his care planned short term goal, the resident would express satisfaction with his daily routines and preferences. The care plan read his preferences and routines would be accommodated by staff.
The November 2019 bowel and bladder care plan indicated Resident #93 is incontinent of urine.
The November 2019 skin care plan identified the resident was at risk for skin breakdown with actual breakdown. According to the care plan, the resident had a pressure ulcer to his left buttock.
VII. Resident #193
A. Resident status
Resident #193, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included intra articular fracture of lower end of right radius, osteoarthritis of the knee, the presence of a left artificial knee joint, history of TIA and cerebral infarction, unsteadiness on feet, difficulty walking, lack of coordination, and generalized muscle weakness.
The resident was a new admission to the facility. A completed minimum data set (MDS) assessment was not available for review.
The November 2019 ADL care plan identified the resident was dependent for ADL care in bathing, grooming, personal hygiene, dressing, transfer, locomotion, and toileting.
B. Resident interview
Resident #193 was interviewed on 11/20/19 at 10:00 a.m., during the resident group interview. According to the resident, she had not received a shower since admission, and would like to be offered one.
Resident #193 was interviewed on 11/21/19 at 12:40 p.m. She said she was told she could have a shower three times a week. She said she requested to have a shower this morning.
-At 4:32 p.m., the resident said she still had not been offered a shower and hoped she received her requested shower the following day. She said she preferred a shower every couple of days.
Resident #193 was interviewed on 11/25/19 at 12:08 p.m. The resident stated she received her first shower on 11/22/19, after multiple requests. Resident #193 said she was happy to have received the shower because her head was starting to itch and she felt like she smelled. She said she was provided a bathing schedule on 11/21/19, indicating she could have a shower three days a week. She said she would request a shower today so she could receive a shower in a few days.
C. Record review
The November 2019 bathing record for Resident #193 identified the resident received a shower on 11/22/19, five days after admission. According to the record, all other dates between 11/17/19 and 11/21/19 were not applicable. The record did not show the resident received a bath/shower, or a bed bath. The record did not show the resident was unavailable for a bath or shower, or refused a bath or shower.
The November 2019 preference care plan read it was important to the resident to have an opportunity to engage in daily routines that are meaningful relative to her preferences. According to her care planned short term goal, the resident would express satisfaction with her daily routines and preferences. The care plan read her preferences and routines would be accommodated by staff.
A bathing preference sheet, provided to, and signed by the resident on 11/21/19, identified the resident wanted showers three days a week.
VIII. Staff interviews
The certified nurse aide (CNA) #3 was interviewed on 11/20/19 at 12:40 p.m. She said she was responsible for 16 residents today. She said they did not have bathing aide in the facility and showers were a primary CNAs responsibility. She said on the days when three CNAs were scheduled to work the unit, they would have three to four showers to complete per CNA. On the days when they had only two CNAs on the unit, they would have up to six scheduled showers per CNA. She said with such a workload it was impossible to accommodate any additional showers. She said she received a few additional requests for showers during her shift but was not able to accommodate it because she was busy giving showers to residents that were scheduled that day.
CNA #2 was interviewed on 11/21/19 at 12:59 p.m. She said they had only two CNAs working today on the unit. She said it was a rehab unit and residents had a lot of care needs. She said they had 3-4 residents on the unit that required two person assistance. She said today she was able to complete all showers because some showers were done by a third CNA that left earlier and some showers were refused by residents. She said on the days when only two CNAs were scheduled to work on the unit, they were not able to complete all showers. She said she communicated that to nurses and nurse managers but did not receive any feedback or additional help.
The DON was interviewed on 11/25/19 at 2:52 p.m. She said bathing preference sheets should be included during the admission process. She said bathing preference should be honored as close as possible.
Based on observations, interviews, and record review; the facility failed to honor resident choices for six ( #243, #246, #27, #29, #93, and #193 ) out of 25 resident's reviewed for self-determination.
Specifically, the facility failed to ensure Residents #243,#246, #27, #29, #93, and #193 received showers according to their choice of frequency.
Findings include:
Cross-reference F725 failure to provide sufficient staffing.
I. Facility policy and procedure
The Activities of Daily Living (ADL) policy, revised 11/1/19, was provided by the Clinical Regional Consultant (CRC) on 11/25/19. It read, in pertinent part, Based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. Activities of daily living (ADLs) include: Hygiene- bathing, dressing, grooming, and oral care. ADL care is documented every shift by the nursing assistant on an ADL flow record or in electronic medical records. The ADL flow record will be reviewed at morning meetings.
II. Resident #243
A. Resident status
Resident #243, age below 70, was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO) diagnoses included acute and subacute infective endocarditis, pain, weakness, and morbid obesity.
The 11/29/19 minimum data set (MDS) assessment revealed the resident had mild cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. She required two person extensive assistance with bathing.
B. Resident interview
The resident was interviewed on 11/20/19 at 11:32 a.m. She said she would like to shower every other day, but nobody asked her what her preferences were. She said she had only received one shower since her admission to the facility on [DATE].
C. Record review
The comprehensive care plan, revised 11/18/19, revealed the resident required assistance for ADL care in bathing related to recent illness, hospitalization, and activity intolerance. The facility failed to identify interventions related to bathing on the comprehensive care plan.
The resident bathing schedule preference sheet revealed the resident's showers were scheduled for Wednesday, Friday, and Sunday in the evening. The resident's representative signed the preference schedule upon admission on [DATE].
Review of the certified nurse aide (CNA) shower record revealed the resident had not received a shower in eight days, since admission to the facility on [DATE].
III. Resident #246
A. Resident status
Resident #246, age above 70, was admitted on [DATE]. According to the November 2019 CPO, diagnoses included aftercare following joint replacement surgery, right artificial shoulder joint, weakness, pain, and difficulty in walking.
The 11/21/19 MDS assessment was not completed yet.
B. Resident interview
Resident #246 was interviewed on 11/19/19 at 1:06 p.m. She said she had only received one shower since admission by her occupational therapist. She said she took a shower every day at home but would be ok with three showers per week while in the facility.
C. Record review
The comprehensive care plan, revised 11/19/19 revealed the resident was at risk for decreased ability to perform ADLs related to right shoulder arthroplasty and limited limited range of motion. The care plan failed to identify interventions related to bathing on the comprehensive care plan.
The resident's shower preferences sheet revealed the resident's shower schedule was Monday, Thursday, and Saturday. The resident signed and agreed to this schedule on 11/14/19.
The resident's shower record revealed the resident had not received showers from a CNA from 11/14/19 to 11/21/19. A therapy progress note revealed the resident receive one shower from her occupational therapist on 11/19/19 due to resident's request at the time of therapy (five days after admission).
D. Staff interviews
CNA #4 was interviewed on 11/21/19 at 3:20 p.m. She said they documented shower preferences in a book at the nurse's station and documented the showers given in the electronic medical records. She said the nurse managers updated the shower preference sheets and checked the books.
The CRC was interviewed on 11/25/19 at 10:35 a.m. She said the facility was unable to locate and shower documentation for Resident #243, #193, #93, #27, #246, and #29. She said an action plan was implemented, during survey, to immediately to offer showers to all residents. The director of nursing (DON) was interviewed on 11/25/19 at 2:42 p.m. She said there was currently not a unit manager on the west unit where Residents #243 and #246 resided.
She said the unit managers were supposed to follow-up on shower records to ensure all showers were provided for residents as preferred. She said the nurses asked residents their preferred shower days upon admission, then added them to the shower schedule. She said showers should be documented by CNAs in the shower book at the nurse's station or in the electronic medical records. She said if the CNAs need assistance then occupation therapists or managers will provide showers. She said she had not been told by any CNAs that they needed assistance with showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the comprehensive care plan for one (# 97) resident out of three sample residents was reviewed and revised by the interdisciplinary team.
Specifically, the facility failed to ensure Resident #97's care plan was updated with new risks and interventions after resident's fall on 11/18/19.
Findings include:
I. Resident #97
A. Resident status
Resident #97, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, paraplegia, anxiety disorder, major depressive disorder, and insomnia.
The minimum data set (MDS) assessment for the resident was not completed. Resident's brief interview for mental status (BIMS) score was not conducted. During the interview the resident was able to answer simple questions, he was oriented to place and situation. Resident #97 was using a manual wheelchair for ambulation.
B. Record review
According to the physician note on 11/24/19, resident had a fall on 11/18/19. Physician recommended to monitor resident for safety.
According to the incident report resident had a fall on 11/18/19. He was assessed by registered nurse (RN) after the fall. The note read that resident was found on the floor by the side of the night stand. Resident said he was trying to go to the bathroom.
-No new interventions were discussed in incident report.
-No new interventions were documented in the residents care plan either.
The resident's care plan for falls was reviewed on 11/21/19 at 5:00 p.m. Resident's comprehensive care plan revealed that the resident was at risk for falls due to recent illness. The care plan was dated with initiation date of 10/11/19 (prior to most recent admission date on 11/12/19). All initiated interventions were dated 10/11/19 as well.
-The care plan did not mention resident's fall on 11/18/19. There were no new interventions added to the care plan after the fall on 11/18/19.
C. Staff interview
The assistant director of nursing (aDON) was interviewed on 11/25/19 at 1:09 p.m. She said she was in charge of updating care plans and make sure they were current and accurate. She reviewed the care plan for Resident # 97 and said it was not updated after the fall. She said she was very busy today as she was working as a floor nurse today and needed to complete a discharge packet for one of her residents. She said she will look into that closely when she will be done with the floor duties.
The director of nursing (DON) was interviewed on 11/25/19 at 1:09 p.m. She said Resident #97 should have specific care plan for falls with individual interventions. She said it was important to have information regarding new approaches to prevent any further falls from happening.
D. Facility follow-up
On 11/25/19 the regional nurse consultant (RNC) provided a printed copy of the care plan specific to the fall, and stated it was updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure two (#40 and #20) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 24 sample residents.
Specifically, the facility failed to:
-Routinely monitor the surgical incision on the back, and timely communicate changes in incision to the physician for Resident #40. Resident developed purulent drainage from the wound and was sent to the emergency room for evaluation; and,
-Complete skin assessments timely, and to monitor bruising and abrasions for Resident #20.
Findings include:
I. Facility policies and procedures
The skin assessment policy was requested from the director of nursing (DON) on 11/21/19. She provided the policy for Nursing Assessment. The policy did not include any information regarding skin assessment and surgical wound care treatments.
The Nursing Assessments policy, revised 11/1/19, was provided by the Regional Nurse Consultant on 11/25/19. It read, in pertinent part, The Center will conduct initially and periodically a comprehensive, standardized, reproducible assessment of each patient's functional capacity. The assessment must accurately reflect the patient's status at the time of assessment. A nursing assessment will be performed by a licensed nurse for all patients within 24 hours of admission. Routine and focused assessments will be performed on an ongoing basis as needed. Complete focused assessments/evaluations as triggered. Complete subsequent assessments/evaluations per the nursing assessment schedule.
II. Resident status
A. Resident #40
Resident #40, age [AGE], was admitted on [DATE], and discharged to acute care facility on 11/15/19. According to the October and November 2019 computerized physician orders (CPO), diagnoses included spinal surgery, morbid obesity, long term use of anticoagulants.
The 11/7/19 minimum data set (MDS) assessment revealed the resident was cognitive intact, her brief interview for mental status (BIMS) score was 15 out of 15. She required extensive assistance of two people with bed mobility and transfers. Resident was at risk for developing skin conditions and she was admitted with surgical wound.
B. Resident interview
Resident was interviewed on 11/20/19 at 11:02 a.m. She said a registered nurse (RN) looked at the incision and changed the dressing on the morning after her admission and then three days later. She said no one bothered to look at the wound or change the dressing until she started complaining of increased pain in her incision site and she had seen the sheets and her pillow were soaked with some yellowish discharge on [DATE].
She said she noticed on this day no nurse had looked at her wound or change the dressing for nine days. She said she was asking the nursing staff to tell the physician, who was in the facility full-time, every day, to come and see her because of the pain increase, and her physician was not notified until the last day when physicican came, he sent her to the hospital with the infection
C. Record review
1.Hospital discharge summary
According to the Discharge summary dated [DATE] from the hospital, Resident #40 was discharged after spinal surgery. Her discharge summary did not include any orders for wound care.
2. Facility records
The resident's care plan, initiated on 10/31/19, revealed the resident was at risk for developing skin problems due to recent surgical incision. Interventions included to observe skin daily for signs and symptoms of skin breakdown, observe for verbal and non verbal signs of pain related to the wound, and provide wound treatments as ordered.
-The care plan was not specific to the incision on the resident ' s back.
According to the physician orders on admission, 10/31/19, the resident was to be monitored daily for status of surrounding tissue and wound pain, as well as the status of the dressing to the area.
According to the medical administration record (MAR) for November 2019, nurses signed the MAR daily for wound monitoring. This would be inaccurate according to the resident, see resident interview above.
III. Failure to assess wound daily
According to skilled daily notes and skin assessments, resident ' s incision was not assessed daily.
The skin assessment on admission, 10/31/19 mentioned resident had incision on her mid back. The assessment did not include a description of the wound size, status of dressing, and/or presence of steri strips or staples.
Skilled notes between 11/1/19 and 11/7/19 were incomplete, skin section of the assessment was left blank.
On 11/8/19 skilled note read back incision, appeared reddened, brownish tissue noted between upper incisions. Otherwise healthy and healing. Free of offensive odor. States pain increased [after physical therapy] on 11/7/19 due to increased strain to the area.
Skilled notes between 11/9/19 and 11/10/19 did not include any notes on skin, skin assessment section was left blank.
The skin assessment note dated 11/10/19 read in pertinent part: lower back incision, draining purulent drainage, with foul odor, dressing changed, [physician] notified via email. Wound size and description were not documented.
Skilled notes between 11/11/19 and 11/14/19 did not include skin assessments. Skin assessment section on above skilled notes was left blank.
According to the progress note on 11/15/19, resident was transferred to the hospital due to incision to back-infection and drainage.
IV. Failure to timely communicate wound condition to the physician and obtain wound care treatment
According to the skin assessment note dated 11/10/19 lower back incision, draining purulent drainage, with foul odor, dressing changed, [physician] notified via email, resident experienced change of condition. No further note regarding new orders or if physician was contacted again.
According to the physician orders, wound care treatments started two days after the change of condition.
On 11/12/19 physician wrote an order to: clean lower back incision and change dressing twice
a day two times a day for wound infection.
According to the physician note, resident was assessed on 11/15/19, resident still having significant amount of drainage from her back incision, need to change dressing 3-4 times a day.
Later that day Resident #40 was transferred to the emergency room for evaluation of her wound.
According to hospital admission record, resident was admitted on [DATE], and presented from [nursing facility] with wound drainage. Was at [nursing facility] and wound started to drain with small area of dehiscence so [resident] was sent to [emergency department] for evaluation.
Resident was evaluated by the physician in the emergency room, the physician evaluated wound and did not think it was infected but rather the result of hematoma development and fat necrosis and pressure from laying in bed for prolonged periods of time in setting of morbid obesity.
V. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 11/25/19 at 12:05 p.m. She said surgical incision were monitored daily and results of the assessment documented in daily skilled notes.
The assistant director of nursing (aDON) was interviewed on 11/25/19 at 1:12 p.m. She said
surgical incisions should be documented on skin integrity report. She said it was important to monitor surgical incisions to make sure they do not get infected and healed appropriately. She said nurses were documenting skin assessment on daily skilled notes and on weekly skin assessments.
The DON was interviewed on 11/25/19 at 2:43 p.m. She said all skin conditions, including surgical incisions should be initially documented on admission assessment. Later, incision site should be documented in daily skilled notes under skin assessment section. She said all incisions should be monitored for signs and symptoms of infection. She said most residents discharged from hospitals with detailed orders for dressing changes.
In cases when resident discharged without specific orders for dressing changes, such orders should be obtained from the physician on admission. She said any changes in wound condition should be communicated to the physician at the time such changes were identified. She said it was expected from nurses to contact the physician to obtain and clarify order the same day if physician have not returned the call.
VI. Resident #20
A. Resident status
Resident #20, age below 70, was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO) diagnoses included osteomyelitis in right ankle and foot, end stage renal disease, diabetes mellitus type II, and cognitive communication deficit.
The 11/1/19 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. He had one unhealed pressure ulcer, a surgical wound, and an infection of the foot.
B. Record review, failure to consistently monitor residents skin
The comprehensive care plan, revised 11/1/19, revealed the resident was at risk for skin breakdown related to moisture associated skin damage to coccyx and bilateral buttocks, port to dialysis, surgical incision, and stage one pressure ulcer upon admission. Interventions included observe skin for signs or symptoms of skin breakdown, evaluate for any localized skin problems, and provide wound treatment as ordered.
The weekly skin assessments were requested from the facility on 11/20/19. The regional nurse consultant (RNC) said there was only one assessment, which was completed on 11/5/19. The assessment revealed the resident had a stage one pressure ulcer on his coccyx.
-The assessment did not identify any bruising.
On 11/26/19, the nursing home administrator provided additional skin assessments for Resident #20. The 11/12/19 skin assessment was signed by licensed practical nurse (LPN) #2 on 11/20/19, after the documentation was requested during the survey and was not previously and readily accessible.
The 11/21/19 skin assessment revealed the resident had a bruise to his upper thigh. The documentation revealed the resident knew it was from surgery a couple weeks ago, however there was no prior documentation of measurements to monitor healing. The skin assessment also did not include measurements of the bruise and scattered abrasions to his left lower leg.
C. Observations
A skin assessment was done on Resident #20 with LPN #2 on 11/21/19 at 3:46 p.m The following skin integrity concerns were observed:
-Six bruises that measured approximately three centimeters (cm) in diameter, the LPN did not measure the bruises;
-Redness to his groin area;
-Left inner thigh bruise approximately three cm by one cm, the LPN did not measure the bruise;
-Four small scabs on his left knee;
-One scab on his left lower leg which measured 1 cm;
-One scab on his left lower leg which measured 0.4 cm by 0.3 cm;
-One on his left lower leg which measured 0.7 cm by 0.3 cm;
-One abrasion on his ankle which was not measured because the LPN threw away the measuring tape. It was estimated to be 1 cm by 0.5 cm. The resident was unable to determine how he got this; and
-Discoloration to his buttocks which measured 8 cm by 6 cm.
D. Staff interviews
LPN #2 was interviewed on 11/21/19 at 3:52 p.m. She said she did not measure or document bruising on the skin assessments unless the bruise covered a large portion of the body. Like a limb or large body bruise. She said the resident was alert and oriented and was able to tell staff how he got the injuries so they did not document.
The director of nursing (DON) was interviewed on 11/25/19 at 2:42 p.m. She said skin assessments were completed on admission, and weekly. She said skin assessments should include rashes, abrasions, surgical incisions, significant tears, wounds, and significant bruises. She said a bruise from an injection would not be considered significant but all other bruises should be documented. She said the skin assessments should be documented at the time it was completed or by the end of that shift in the electronic medical records or in the paper charts. She said all bruises and wounds should be measured and documented to be able to monitor for healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for one (#195) of one resident reviewed for supplemental oxygen use out of 25 sample residents.
Specifically, the facility failed to:
-Ensure staff followed current physician's order for use of oxygen;
-Obtain orders to establish parameters to maintain acceptable oxygen levels;
-Obtain orders to establish why the resident required oxygen to include liter flow rate when Resident #195 was below the appropriate saturation levels;
-Ensure the care plan included specific oxygen use instructions for staff to follow; and,
-Ensure the resident maintained safe oxygen saturation levels.
Findings include:
I. Facility policy and procedure
The respiratory management policy and procedure, provided by the director of nursing (DON) on 11/25/19, revealed, in pertinent part, Patients will be assessed for the need for respiratory services as part of the nursing assessment process. If respiratory care is needed, it will be performed by a licensed nurse who has been trained on the procedure and demonstrated on competency. Certain respiratory treatments may be performed by non-licensed staff with appropriate training per state regulation.
II. Resident #195
A. Resident status
Resident #195, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), diagnoses included wedge compression fracture of the fourth lumbar vertebra, multiple fractures of ribs and history of falling.
The resident was a new admission to the facility. A completed minimum data set (MDS) assessment was not available for review.
B. Record review
The November 2019 CPO revealed the resident had an order for oxygen at two liters per minute (LPM) continuously via nasal cannula. The oxygen order was started on 11/17/19. The order indicated to document every shift.
-The CPO did not show parameters for use based on oxygen saturation levels. The CPO did not document directions in the oxygen order for when the resident's oxygen saturation level dropped below 90%.
The November 2019 care plan read Resident exhibits or is at risk for respiratory complications related to chronic respiratory failure. According to the care plan, she should be in an upright position to facilitate respirations, encourage coughing and deep breathing and be reminded to use the incentive spirometer.
-The care plan did not include the need for supplemental oxygen use, interventions for use or staff directions for specific oxygen care. The care plan did not include the resident removed or needed assistance with monitoring use.
The November 2019 medication administration record (MAR) indicated the resident's oxygen levels ranged from 88% to 98% via nasal cannula.
The 11/25/19 progress note read Resident #195 had chronic respiratory failure with a history of restrictive lung disease (kyphoscoliosis). According to the note, the resident was to use oxygen 24 hours a day while recovering from rib fractures.
C. Resident interview and observations
Resident #195 was observed on 11/19/19 at 10:01 a.m. She sat in a lounge chair in her room. Beside the resident, between the chair and the bathroom doorway was an oxygen concentrator. The concentrator was not on. The resident did not wear the nasal cannula tubing attached to the oxygen concentrator. The tubing was coiled on top of the concentrator. The resident was not wearing her oxygen as ordered via oxygen concentrator or portable concentrator.
Resident #195 was interviewed on 11/20/19 at 2:40 p.m. with her visiting family. The resident was observed sitting in the lounge chair. The oxygen concentrator was turned on and set at 2 liters per minute (LPM). The resident was not wearing the nasal cannula attached to the concentrator. The daughter said Resident #195 had just returned from therapy. The resident said she did not wear oxygen during the therapy session.
The resident said she did not have a portable oxygen tank to wear during the therapy session. The resident ' s daughter said the therapist did not offer use or reminder of oxygen use during or after the therapy session and no other staff had helped her. The resident said she needed assistance putting the oxygen on. The resident ' s son placed the nasal cannula tubing in the resident ' s nares.
Resident #195 was observed on 11/21/19 at 12:08 p.m. in the therapy gym. She did not wear oxygen via nasal cannula. A portable oxygen concentrator was not attached to the resident ' s wheelchair.
The resident was observed on 11/25/19 at 10:31 a.m. The resident walked with a walker down the hall with a family friend. The resident did not wear oxygen as she walked down the hall towards her room. A portable oxygen tank was not attached to the resident ' s walker. The assistant director of nursing (ADON) was positioned at a nursing cart, in the hall, next door to the room of Resident #195.
-At 10:35 a.m, the resident walked towards the ADON and requested medicine for her pain. The ADON, observing the resident, did not encourage or assist her with the use of oxygen.
-At 10:39 a.m. the ADON approached the resident as she stood near the entrance to her room, and asked the resident ' s pain level. The ADON did not encourage or assist her with the use of oxygen.
-At 10:41 a.m., the resident informed her friend she was very tired and slowly entered her room, having to hold on the wall with her left hand as she pushed her walker forward.
-At 10:45 a.m., the resident ' s friend assisted the resident in her lounge chair. The oxygen concentrator was on, the resident did not have the nasal cannula in her nares. The tubing remained on top of the concentrator, out of reach of the resident.
-At 10:46 a.m., the ADON entered the resident ' s room and administered her pain medication. The ADON exited the room without encouraging or assisting the resident with her oxygen from her running oxygen concentrator.
-At 10:54 a.m., the resident sat in her chair with her eyes closed, leaning to her right side. She was not wearing oxygen.
-At 11:08 a.m., the ADON observed the resident not wearing her ordered oxygen. The ADON woke the resident and applied a pulse oximeter to measure the resident ' s oxygen saturation levels.
-At 11:10 a.m. the ADON said the resident ' s saturation level was at 66% at room air. She placed oxygen in nares of Resident #195 via her running oxygen concentrator. The resident ' s saturation levels rose to 94%. She instructed the resident to exhale into an incentive spirometer. She told the resident that she needs to use the spirometer every hour, as much as she can to expand her lungs.
IV. Staff interviews
The ADON was interviewed on 11/25/19 at 11:02 a.m. She identified herself as a registered nurse (RN) and the unit manager. She said Resident #195 should wear her oxygen continuously. She said all direct care staff who work with Resident #195 should be aware that the resident should always have her oxygen on and assist as needed.
The ADON said the resident ' s normal saturation levels run between 91% and 96%. The nurse acknowledged the resident ' s oxygen orders did not establish parameters to maintain acceptable oxygen levels or liter flow rate when Resident #195 was below the appropriate saturation levels. According to the ADON, she said she also could not find an order to monitor the resident ' s oxygen.
-At 11:17 a.m., the ADON identified the resident ' s 11/25/19 oxygen saturation level was at 66%. According to the ADON, a saturation level at 66% would be very low for anyone. She said the resident would need to use a spirometer for the rest of the day.
An occupational therapy assistant (OTA) #1 was interviewed on 11/25/19 at 2:21 p.m. OTA #1 said therapy staff should be aware of the supplemental oxygen use and need of Resident #195 when conducting a therapy session.
The director of nursing (DON) was interviewed on 11/25/19 at 2:47 p.m. She said any resident who received supplemental oxygen, should have a physician's order. The DON said the orders should provide a clear direction for staff. She said a physician order should be obtained by nursing for oxygen use of each resident. She said oxygen use should be monitored by the nurse, and all staff, including therapy, should be aware of the usage. The DON said supplemental oxygen should be on the MAR and the care plan. She said the resident ' s care plan should include specific oxygen use instructions for staff.
The DON said the oxygen saturation level of Resident #195 should be maintained above 88%. She said she was informed of the resident's low oxygen level at 66%, and the physician was alerted. The DON revealed she directed her staff to conduct a facility wide audit on all residents with supplemental oxygen orders to ensure appropriate use and ensure safe oxygen saturation levels. The DON said she also provided staff education for resident oxygen use.
V. Facility follow-up
The nurse consultant provided a revised oxygen care plan on 11/25/19, after oxygen concerns were identified. The care plan included:
-Medicate as ordered and monitor for effectiveness, observing signs and symptoms of side effects, and report to the physician as indicated;
-Monitor and record lung sounds every shift and report to the physician as needed;
-Monitor and report oxygen saturation levels via pulse oximetry as ordered and as needed;
-Provide oxygen as ordered via nasal cannula;
-Observe the respiratory rate, signs and symptoms of dyspnea, use of accessory muscles indicating respiratory distress and report to the physician as needed; and
-Observe respiratory status and assess for changes, including changes in mental status.

Based on record review and interviews the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required to achieve their highest practicable physical, mental, and psychosocial well-being.
Specifically, the facility failed to ensure enough staff were available to adequately care for the resident as residents felt and expressed their activities of daily living (ADLs) of toileting assistance, transferring, showers, and overall call light response, were met and addressed in a timely manner.
-Cross-reference F561, failure to honor resident ' s choice regarding showers.
I. Resident interviews
Resident #194 was interviewed on 11/19/19 at 9:40 a.m. She said she often had to wait 20 to 30 minutes to use the restroom after putting on her call light.
Resident #5 was interviewed on 11/19/19 at 10:19 a.m. He said he believed the facility did not have enough staff everyday. He said depending on the time of day and the number of staff available, he often had to wait a long time for his call light to be answered. He said he was told by a staff member that she was considering leaving because staff could not deliver the level of care needed to all the residents because of short staff. He said sometimes he had to wait over an hour for assistance.
Resident #243 was interviewed on 11/19/19 at 10:25 a.m. She said it takes a long time to get help when she puts on the call light.
Resident #196 was interviewed on 11/19/19 at 12:18 p.m. She said she had to wait on average 15 to 20 minutes to have her call light answered. She said she one evening, she put her call light on to request her scheduled pain medication. She said she had to wait two hours before she had a response. She said she was told that staff was short and they were waiting on more staff to come in to help.
Resident #246 was interviewed on 11/19/19 at 12:34 p.m. She said she is sometimes left on the toilet for a long time waiting for the CNA to return.
Resident #247 was interviewed on 11/19/19 at 12:50 p.m. He said staff needed to answer the call light quicker and check to see what the resident needed. He said he sometimes had to wait 20 minutes for them to respond.
Resident #27 was interviewed on 11/19/19 at 2:38 p.m. She said she had to sometimes wait an hour for staff to respond to her call light when she required a two person assist with ADL ' s.
II. Group interview
A group interview was held on 11/21/19 at 10:00 a.m. with four alert and oriented residents selected by the facility for participation. The residents said they felt the CNA ' s worked hard but were short handed, resulting in long light waits, limited showers, and slow deliveries of meal room trays. Resident #7 said he frequently had to take himself to the restroom after having to wait for his call light to be answered. He said he was unsteady on his feet and needed a wheelchair for mobility. All residents stated they reported concerns to the DON.
III. Observations
Resident #193 was observed on 11/19/19 at 9:25 a.m. She laid flat on her bed with her breakfast tray in front of her on an over the bed table. She said she needed to be repositioned with her bed raised so she could eat her meal and could not do it herself.
-At 9:26 a.m., she placed her call light on.
-At 9:28 a.m., a housekeeper passed the room of Resident #193 and entered the room next door. She did not respond to the call light of Resident #193.
-At 9:31 a.m., a non uniformed staff member walked to and from the nursing cart directly across from the room of Resident #193. She did not respond to the call light the resident ' s call light.
-At 9:35 a.m., the housekeeper exited the room next door to resident #193. She did not respond to the call light.
-At 9:36 a.m., a therapist was observed exiting a room directly across the hall from Resident #193. The call light was not responded to.
-At 9:38 a.m. CNA #2 responded to call light of Resident #193. The CNA repositioned the resident so she could eat her meal.
IV. Record review
The Census and Conditions of Residents form, provided by the facility and dated 11/19/19, revealed 51 residents resided in the facility. Care needs of the residents were documented as follows:
-Two residents were dependent on staff for bathing and 17 residents needed the assistance of one or two staff to bath;
-24 residents needed the assistance of one or two staff to dress;
-28 residents needed to the assistance of one or two staff to transfer;
-28 residents needed the assistance of one or two staff to use the toilet;
-18 residents needed the assistance of one or two staff to ear;
-11 residents were frequently or occasionally incontinent of bladder;
-Seven residents were frequently or occasionally incontinent of bowel:
-26 resident were in their wheelchairs all or most of the time;
-Three residents had a diagnosis of dementia;
-Two residents had current pressure injuries and 18 residents received preventative skin care;
-One residents recieved dialysis services;
-Two residents received intravenous therapy, nutritions, and/or blood transfusion
-Nine residents recieved respiratory care;
-Nine residents had contractures;
-19 residents received therapy services;
-Seven on antibiotic therapy;
-13 on psychoactive medication; and
-22 residents were on a pain management program.
The facility assessment was provided on 11/19/19 by the nursing home administrator (NHA). The facility assessment indicated 85% of the resident population required assistance with dressing, bathing, and transferring. The assessment indicated 70% of the population needed assistance in toileting.
Review of a call light audit between 11/9/19 and 11/11/19 revealed out of 73 call light entries, 17 response times were left blank or crossed out. The call light audit revealed in pertinent part call lights at 10 minutes or over.
-On 11/10/19 a call light was placed on at 7:30 a.m. and responded to at 7:40 a.m.
-On 11/10/19 a call light was placed on at 8:00 a.m. and responded to at 8:15 a.m.
-On 11/10/19 a call light was placed on at 8:55 a.m. and responded to at 9:20 a.m.
-On 11/11/19 a call light was placed on at 11:30 a.m. and responded to at 11:40 a.m.
V. Staff interviews
A frequent facility visitor was interviewed on 11/20/19 at 9:12 a.m. She said she was aware of resident call light complaints and was told residents had to call the front desk to request for call lights to be answered.
Certified nursing aide (CNA) #3 was interviewed on 11/20/19 at 12:40 p.m. She said she had 16 residents she needed to provide ADL care for. She said she had difficulty meeting all residents ADL daily care needs such as showers, Cross-reference F561.
CNA #2 was interviewed on 11/21/19 at 12:59 p.m. She said they had only two CNAs working today on the unit. She said it was a rehab unit and residents had a lot of needs. She said they had three to four residents on the unit that required two person assistance.
LPN #1 was interviewed 11/21/19 at 2:37 p.m. She said there was only one CNA working on the west unit at the moment and that CNA was unavailable to be interviewed.
CNA #3 was interviewed on 11/21/19 at 3:11 p.m. She said she was an agency employee. She said she usually worked six days a week, 12 to 14 hour shifts. She said she wanted to have a schedule with less hours but is often asked to work extra to help provide enough staff coverage at this facility.
She said she has seen a lot of facility and agency staff turnover in the past couple of months. She said the CNA ' s try to do their best for the residents with limited, but there was so much to do to care for them. She said the CNA ' s have to run room to room, and do not normally get meal breaks because there was no time. CNA #3 referred to the survey observation period, she said the environment had been calm and very different than usual weeks. She said it was a helpful and needed change to see management and other staff help answer call lights and pass meals. Residents were able to have all their needs timely met with this additional help.
CNA #3 said sometimes she had seen a CNA had to work two to three hours alone on a unit. She said the nurse would help with taking resident vitals but it was impossible for one person to help all the residents with ADL cares, showers and call lights. She said she has refused to be the only CNA covering the unit. She said she could not do it alone.
The director of nursing (DON) was interviewed on 11/25/19 at 10:07 a.m. with the central staff manager (CSM). The DON identified she was the interim DON for the past month and stepped in to the staff scheduler to fill the open position after the previous scheduler left unexpectedly in October 2019.
The CSM said he was hired two weeks ago and was currently responsible for scheduling staff.
The CMS said the facility had three to four CNA shifts open on the 2:00 p.m. to 10:00 a.m. shift and 6:00 p.m. to 6:00 a.m. overnight shift. The DON said they consistently use agency staff to fill open shifts. The CSM said he would like to see three CNAs per unit which would equal to one CNA per hall. He said when there is only two CNA ' s per unit, they have to split a hall.
The DON said that there has never been a time that she was aware of, that there would be only one CNA responsible for covering a unit. The DON said she had heard staff express concerns that they are short staffed, but disagreed with the expressed concerns.
The dietary manager was interviewed on 11/25/19 at 10:57 a.m. He said he received complaints from residents about cold food, but there were not enough CNAs available to pass the room trays before the food got cold. He said CNAs were too busy to reheat food after it cooled down. He said the facility told him they wanted CNAs to observe food texture before it was served to the residents and they did not want the kitchen staff to assist with room trays.
The director of nursing (DON) was interviewed again on 11/25/19 at 2:52 p.m. She said she expected call lights to be answered as soon as possible, with a maximum of an eight minute wait.
She said all staff should answer call lights. She said she instructed her staff to conduct call light audits after she heard residents expressed long call light wait times. She reviewed the call light audit record between 11/9/19 and 11/10/19. She said she had not seen all of the call light results. She said she did not know why some of the call light response times were left blank or crossed out. She said the audit record did not give clear results of resident call light response time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#97) of five residents reviewed out of 25 sample residents were reviewed by interdisciplinary team after pharmacy submitted monthly recommendations.
Specifically, the facility failed to:
-Timely communicate/deliver all pharmacy recommendations to the physician for review, and
-Follow up with the physician regarding the pharmacist recommendations for Resident #97.
I. Resident #97
A. Resident status
Resident #97, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, paraplegia, anxiety disorder, major depressive disorder, and insomnia.
The minimum data set (MDS) assessment for the resident was not completed. Resident ' s brief interview for mental status (BIMS) score was not conducted. During the interview resident was able to answer simple questions, he was oriented to place and situation.
B. Record review
A review of the physician orders for November 2019 revealed the following relevant orders:
-Melatonin tablet 5 milligram (mg), give 15 mg by mouth at bedtime for insomnia. Effective 11/12/2019.
-Remeron tablet 45 mg by mouth at bedtime for insomnia. Effective 11/12/2019.
-Temazepam Capsule 7.5 mg, give one capsule by mouth as needed for insomnia. Effective 11/15/2019.
-Paroxetine tablet 20 mg, give one tablet by mouth one time a day for depression. Effective 11/13/2019.
Risperidone tablet one mg, give one tablet by mouth two times a day for dementia with behaviors. Effective 11/12/2019.
The 11/13/19 pharmacist report included four recommendations:
1. To provide risk benefit statement as resident was receiving two antidepressants concomitantly: Remeron 45mg and Paxil 20mg;
2. To consider discontinuing albuterol, at least at bedtime, and use alternative therapy if needed. Resident received scheduled albuterol twice a day and had symptoms of restlessness, and insomnia, which were common possible side effects of albuterol.
3. To administer tamsulosin capsules at least 30 minutes after the same meal every day to decrease the risk and adverse side effects. Capsules were scheduled at 8 a.m. in the morning.
4. To separate the administration of eye drops. Resident was receiving multiple ophthalmic drugs at one administration time.
The medication administration record (MAR) for November 2019 revealed no changes were made based on pharmacist recommendations until 11/20/19 (the day when recommendations were requested for the survey). Recommendation #3 and #4 were addressed by nursing staff on 11/20/19. Recommendations #1 and #2 were not addressed at all.
II. Interviews
Certified nurse aide (CNA) #4 was interviewed on 11/21/19 at 11:28 a.m. She said resident took two to three naps during the day and in general he can sleep all day long if we let him. She said resident ' s wife was asking them to keep resident up in the morning so he can sleep better at night. She said resident was more restless and active during the evenings.
Pharmacy service consultant (PSC) was contacted via the phone on 11/21/19 at 4:35 p.m. She said she documented a total of four recommendations on 11/13/19 to the facility. She provided copies of her recommendations by email. She said she did not know if any of her recommendations were addressed as her follow up visit was not due yet.
Physician assistant (PA) was interviewed on 11/25/19 at 12:35 p.m. She said pharmacy recommendations were dropped by staff members to the physician mailbox. She said all the physicians who were in the office would address recommendations the same day. She said once recommendations were addressed they were placed in the paper chart. She reviewed the recommendations and said she did not recall having these notes from the pharmacist.
The director of nursing (DON) was interviewed on 11/25/19 at 2:46 p.m. She said she was new to this position and have been working in the facility for the last three weeks. She said she received all recommendations by email and since she started her position she received over 800 emails and was not able to go through all of them.